DC-600S DOMESTIC RELATIONS

COURT CASE FORMS – DOMESTIC RELATIONS

DC-600 SERIES

DISTRICT COURT MANUAL

FORMS VOLUME

Form DC-601 NOTICE – ADMINISTRATIVE SUPPORT Form DC-601 DECISION APPEAL

Using This Form 1. Copies

a. Original - to court. b. First copy – to Division of Child Support Enforcement. c. Second copy – to appellant.

2. Top portion prepared by appellant, bottom portion prepared by court. 3. Attachments – none. 4. Preparation details –

Data Elements Nos. 11 and 12--allow at least two weeks for DCSE to transmit the requested material, then set the court hearing date for a date later than the expected delivery date.

DISTRICT COURT MANUAL FORMS VOLUME OCTOBER 2002

NOTICE — ADMINISTRATIVE SUPPORT DECISION APPEAL Commonwealth of Virginia Va. Code § 63.2-1943 Case No.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 DCSE ID No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juvenile and Domestic Relations District Court 3 Virginia Department of Social Services, Division of Child Support Enforcement

ex rel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 5 . . ADDRESS/LOCATION ADDRESS/LOCATION

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone No. (H) . . . . . . . . . . . . . . (W) . . . . . . . . . . . . . . . . . . . . . . Telephone No. (H) . . . . . . . . . . . . . . (W) . . . . . . . . . . . . . . . . . . . . Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Names of Dependents Date of Birth Relationship to Defendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I appeal the decision of the hearing officer in the above-styled case and ask that this court try the case without considering the decision of the hearing officer as an appeal de novo pursuant to Virginia Code § 63.2-1943 as applicable. The order appealed involved:

[ ] Administrative support order [ ] Notice and finding

7 [ ] Mandatory withholding of earnings [ ] Order to withhold and deliver [ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The city or county in which this court is located is a proper location for this hearing because it is where: [ ] I reside

8 [ ] the appellee resides and I do not reside in Virginia [ ] either the obligor’s property or the place of business of the obligor’s employer is located and neither the appellee nor I reside in Virginia

I understand that the decision of the hearing officer remains valid and enforceable during the appeal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________ DATE SIGNATURE OF APPELLANT

9 10

COURT USE ONLY Notice of Hearing

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . is the date and time of the hearing of this appeal. The Division of 11 Child Support Enforcement is directed to forward a copy of the hearing officer’s decision by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________________ 13 14 DATE [ ] CLERK [ ] DEPUTY CLERK

FORM DC-601 (MASTER) REVISED 10/02

Form DC-601 NOTICE – ADMINISTRATIVE SUPPORT Form DC-601 DECISION APPEAL

Data Elements

1. Court case number.

2. DCSE ID number of DCSE support case in which the administrative support decision is being appealed.

3. Court name.

4. Name and other data of person on whose behalf the Division of Child Support Enforcement is taking action.

5. Name and other data of person against whom the Division of Child Support Enforcement is taking action.

6. Insert names and data regarding dependents for whom the Division of Child Support Enforcement is seeking support.

7. Check the applicable box and, if applicable, describe the document containing the decision which is being appealed.

8. Check the applicable box.

9. Date of signing by the appellant.

10. Signature of appellant.

11. Date and time of court hearing. See Using This Form, item 4.

12. Date and time by which the Division of Child Support Enforcement is to forward a copy of the administrative support decision to the court. See Using This Form, item 4.

13. Date of signing by the clerk.

14. Signature of clerk or deputy clerk. Check the appropriate box.


Form DC-602 NOTICE OF APPEAL – Form DC-602 SUPPORT PROCEEDING

DISTRICT COURT MANUAL FORMS VOLUME JANUARY 2013

Using This Form

1. This form is to be used for appeals in support proceedings only.

2. Copies

a. Original – to court.

b. First copy – to appellant.

3. Prepared by clerk, signed by appellant.

4. Attachments

a. Case papers for case being appealed.

b. District court form DC-330, RECOGNIZANCE, if appearance bond is required.

c. District court form DC-460, CIVIL APPEAL BOND, if civil appeal bond is required.

FORM DC-602 (MASTER, PAGE ONE OF TWO) 10/12

NOTICE OF APPEAL – SUPPORT PROCEEDING Case No. ...................................................................................... Commonwealth of Virginia VA. CODE §§ 16.1-296, 16.1-298

.................................................................................................................................................................. Juvenile and Domestic Relations District Court CITY OR COUNTY

................................................................................................................................................................................................. Date of Final Order or Judgment .................................................................................................................. v. /In re. .................................................................................................................................. Appellant: .................................................................................................................................................................................................................................................. NAME AND ADDRESS Appealed to the ........................................................................................... Circuit Court ................................................................................................................ CITY OR COUNTY TELEPHONE NUMBER ........................................................................................................................................................................................................................................................................

STREET ADDRESS

Date and Time of Appearance in Circuit Court: ................................................................................. for [ ] Trial [ ] Setting of Trial Date I, the undersigned, note an appeal to the following conviction, judgment or final order:

[ ] CIVIL SUPPORT PROCEEDINGS: (excluding civil contempt finding for nonpayment of support): ..................................................... I understand that the order of judgment from which I appeal remains in full force and effect until modified or annulled by the Circuit Court. If the order being appealed adjudicates or establishes an arrearage, an appeal bond for the arrearage, as described below, is required.

[ ] CRIMINAL NONSUPPORT: Appeal of conviction and order of support. I understand that the order of support from which I appeal remains in full force and effect until modified or annulled by the Circuit Court. An appearance bond and/or accrual bond, if ordered, is described below.

[ ] CIVIL CONTEMPT: An appeal bond for the arrearage required and described below. An appearance bond and/or accrual bond, if ordered, is described below.

[ ] CRIMINAL CONTEMPT: [ ] Appeal of conviction. An appearance bond and/or accrual bond, if ordered, is described below. [ ] Appeal of order establishing support arrearage. An appeal bond for the arrearage required and described below. I understand that this appeal may be withdrawn at any time prior to the hearing date set for my case (see additional information on second page). I promise to appear before the Circuit Court of this jurisdiction on the date and time as shown above.

...................................................................... ____________________________________________________ DATE APPELLANT/ATTORNEY FOR APPELLANT

By order of the Court, bond is required as follows:

An appeal bond for the arrearage in the amount of $ ..................................... must be posted with the clerk of the juvenile and domestic AMOUNT OF ARREARS relations district court within thirty (30) days of the entry of the judgment for the appeal to be completed (perfected) (Form DC-460, CIVIL APPEAL BOND). The Appellant’s failure to do so, as required by law, will result in the loss of the right to appeal. The appeal bond for the arrearage will be written to indemnify ................................................................................................................................................. the party in whose favor a judgment was rendered in this court in the event that such party is awarded a judgment by the Circuit Court. [ ] An accrual bond in the amount of $ .................................... to secure the payment of prospective support while the appeal is pending is

ordered and must be posted with the juvenile and domestic relations district clerk within thirty (30) days of contempt finding/conviction or nonsupport conviction (Form DC-460, CIVIL APPEAL BOND). If the bond is not posted within thirty (30) days and the defendant has been released from jail, a capias may be issued for failure to abide by the conditions of bail.

[ ] An appearance bond in the amount of $ ..................................... [ ] unsecured [ ] secured to ensure appellant’s appearance is

ordered (Form DC-330, RECOGNIZANCE). Further conditions of release: ..............................................................................................................

............................................................................................................................................................................................................................................................. ...................................................................... ________________________________________________________ DATE CLERK

See second page for additional important information.

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3 4 4

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7

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14

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18 19



Data Elements, page one

1. Insert court case number.

2. Insert jurisdiction name.

3. Insert date of final order or judgment.

4. Insert case name.

5. Insert name and address of appellant.

6. Jurisdiction, street address and telephone number of circuit court.

7. Insert date on which the appellant must appear in circuit court and check box for whether it is the date for trial or for setting the trial date.

8. Check box if appealing an order in a civil support proceeding. Enter the actual issue

appealed in the blank. See Data Element No. 16.

9. Check if appealing a criminal nonsupport finding.

10. Check if appealing the order in a civil contempt case. See Data Element Nos. 14-16.

11. Check if appealing the order in a criminal contempt case and further check which issues are being appealed. See Data Element Nos. 14-16.

12. Date of filing of notice of appeal.

13. Signature of appellant or appellant’s attorney.

14. Insert the amount of the appeal bond for the arrearage.

15. Insert name of party in whose favor a judgment for arrears was entered.

16. Check box if an accrual bond is required and insert the amount of the bond.

17. Check box if appearance bond is required, insert the amount of the bond, and check

unsecured or secured box.

18. Date accepted by clerk.

19. Clerk’s signature.

FORM DC-602 (MASTER, PAGE TWO OF TWO) 07/08

NOTICE: Promptly communicate with the Clerk of the Circuit Court of this jurisdiction concerning the subpoenaing of witnesses and any need for interpreters, whether you wish to request a jury trial, and, for criminal cases, concerning your right of representation by a lawyer if you do not have a lawyer. If your case is scheduled for trial, you MUST be present and ready for trial at the “date and time of appearance” shown on the front of this form. WARNING: In criminal cases, you are subject to trial and conviction in your absence if you fail to appear for your case in the Circuit Court. Failure to appear shall be deemed a waiver of your right to trial by jury in this case. Failure to appear may also constitute a separate criminal offense. WITHDRAWAL OF APPEAL IN CIVIL CASES: If this appeal is withdrawn within ten (10) days after entry of the judgment or order when no appeal bond or costs are required to perfect the appeal, or before being “perfected” by posting required appeal bond or paying required costs, no additional costs will be taxed against you. After ten (10) days or after the appeal is “perfected” by posting the required appeal bond or paying required costs, in accordance with § 16.1-106.1, any withdrawal of the appeal must occur in Circuit Court. Upon withdrawal of the appeal in Circuit Court, additional costs will be incurred and any cash bond posted to perfect the appeal may be disbursed. WITHDRAWAL OF APPEAL IN CRIMINAL CASES: If this appeal is withdrawn within ten days after conviction in the juvenile and domestic relations district court, no additional costs will be taxed against you; otherwise, additional costs will be incurred in the Circuit Court. After ten days, any withdrawal of the appeal must occur in Circuit Court. In criminal cases, upon withdrawal of this appeal, you must comply with the terms of the sentence. WITHDRAWAL OF APPEAL I, the undersigned, withdraw my appeal in this case. ...................................................................... _______________________________________________________________________________ DATE APPELLANT by ___________________________________________________________________________ ATTORNEY FOR APPELLANT

1 2

3



Data Elements, page two

1. Date of withdrawal of appeal.

2. Signature of appellant or name of appellant if withdrawn by appellant’s attorney.

3. Signature of appellant’s attorney, if applicable.

Form DC-603 NOTICE OF INFORMATION REQUIRED IN Form DC-603 CHILD/SPOUSAL SUPPORT PROCEEDINGS


Using This Form This form can be given to the Petitioner at the time of filing of the petition and served with the Summons in a support proceeding. The form advises the parties to a support proceeding of the information required by the court at the hearing. Lines have been inserted after each type of requested information to allow the parties to insert the information to bring with them to the hearing.

FORM DC-603 MASTER 10/12

NOTICE OF INFORMATION REQUIRED IN CHILD/SPOUSAL SUPPORT PROCEEDINGS Commonwealth of Virginia Va. Code § 20-60.3

To help you prepare for your hearing, you should complete this form and bring it, along with supporting documentation, with you to your hearing. At your hearing, you will be required to give the Judge the following information about yourself:

1. Your gross income. Gross income “shall mean all income from all sources, and shall include, but not be limited to, income from salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital gains, social security benefits except as listed below, worker’s compensation benefits, unemployment insurance benefits, disability insurance benefits, veterans’ benefits, spousal support, rental income, gifts, prizes or awards. If a parent’s gross income includes disability insurance benefits, it shall also include any amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits.” Gross income “shall not include benefits from public assistance programs as defined in Virginia Code § 63.2-100 [Temporary Assistance to Needy Families (TANF), auxiliary grants to the aged, blind and disabled, medical assistance, food stamps, energy assistance, employment services, child care and general relief]; federal supplemental security income benefits or child support received; or income received by the payor from secondary employment income not previously included in “gross income,” where the payor obtained the income to discharge a child support arrearage established by a court or administrative order and the payor is paying the arrearage pursuant to the order.”

The judge may require that you submit documentation, your most recent pay stub or other statement of your gross monthly income, prior to your hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Your name, address and telephone number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Your Social Security number and date of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . Whether you have a driver’s license and, if so, the driver’s license number and state of issuance. [ ] none

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Place of employment, address and telephone number of your employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Information regarding any license, certificate, registration or other authorization to engage in a profession, trade, business,

occupation, or recreational activity issued by the Commonwealth of Virginia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Whether you or your spouse can provide health care coverage for your children and, if so, who is the health care provider. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. How much the health care coverage will cost to cover your children only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. The cost of day care for your children and the name(s) of the day care provider. The judge may require that you provide documentation of this cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Whether you pay support to another custodian for another child or children. Please have information about the amount and names and ages of other children and the name and address of the custodian available. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. Whether you are providing actual support to other persons. If you are, bring proof of this support to the hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 . Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Form DC-604 ORDER OF REFERRAL AND MEDIATOR Form DC-604 PPOINTMENT ORM USTODY ISITATION AND UPPORT ASES A F – C , V S C

DISTRICT COURT MANUAL FORMS VOLUME JULY 2009

Using This Form

1. Copies

a. Original – to court. b. First copy – to mediator.

c. Second copy – to petitioner.

d. Third copy – to respondent.

2. Attachment – Petition or other pleading in the underlying case. 3. Preparation details – this form is to be used to refer parties to a mediation orientation

session pursuant to Virginia Code § 20-124.4. After the mediation is concluded, the mediator returns his or her copy, or a photocopy, to the court.

ORDER OF REFERRAL AND MEDIATOR APPOINTMENT Case No(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 FORM — CUSTODY, VISITATION AND SUPPORT CASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonwealth of Virginia Va. Code § 20-124.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 CITY/COUNTY

[ ] Circuit Court [ ] Juvenile & Domestic Relations District Court

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v./In re. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Court has determined that the matter on the attached petition(s) or other pleading, which currently is before the Court, is appropriate for referral to a dispute resolution proceeding pursuant to Virginia Code § 20-124.4. It is hereby ORDERED that: 1. Pursuant to the provisions of Virginia Code § 20-124.4, the matter is referred to a dispute resolution orientation

session, for which there shall be no cost to the parties. The orientation session is to be conducted by

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

NAME AND TELEPHONE NUMBER OF CERTIFIED MEDIATOR

who is hereby appointed as the Certified Mediator.

2. [ ] The orientation shall be conducted at a time and location convenient to the parties, to be set by the mediator no

later than thirty (30) days from the entry of this order OR [ ] the orientation session will be held on

5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .m. DATE TIME

6

6

7 3. The issues to be mediated include [ ] custody [ ] visitation [ ] support. 4. A description of procedures for referral to a dispute resolution proceeding is on the reverse and incorporated into this

Order by reference. 5. Irrespective of this referral, this case has been set for return to court, in accordance with the court’s normal docketing

procedures, on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . m. DATE TIME

8

8

The court must be informed in writing if the dispute is resolved prior to the return date or if a continuance is requested to pursue further a dispute resolution proceeding. Otherwise, the parties shall appear in court at that time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________________________________________ DATE JUDGE

9

10

____________________________________________ TO BE COMPLETED BY CERTIFIED MEDIATOR

[ ] Agreement reached in mediation [ ] Agreement not reached in mediation [ ] copy attached [ ] No orientation session or mediation occurred. [ ] copy to be forwarded by parties or counsel.

11 12

13

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __________________________________________

14 DATE CERTIFIED MEDIATOR

15

This form must be attached to district court form DC-40, LIST OF ALLOWANCES, by the clerk of court prior to forwarding to the Office of the Executive Secretary of the Supreme Court of Virginia for payment.


Form DC-604 ORDER OF REFERRAL AND MEDIATOR Form DC-604 APPOINTMENT FORM – CUSTODY, VISITATION AND SUPPORT CASES



1. Case number(s). 2. Name and type of court.

3. Case name.

4. Name and telephone number of mediator to whom case is referred.

5. Check the applicable box indicating when the mediation orientation session is to be held.

6. Date and time of mediation orientation session, if applicable.

7. Identify the issues to be mediated.

8. Next court hearing date and time in the underlying matter.

9. Date of referral order.

10. Signature of referring judge.

11. If mediation agreement reached, check to indicate whether agreement is attached or is to

be forwarded.

12. Check to indicate if no mediated agreement has been reached.

13. Check if no orientation session or mediation occurred.

14. Date completed by mediator.

15. Signature of mediator.


PROCEDURES FOR REFERRAL TO A DISPUTE RESOLUTION PROCEEDING

1. If any party objects to this Order of Referral, a written statement signed by such party must be filed with this court within fourteen (14) days after the entry of this order. The statement must indicate that the dispute resolution process has been explained to the party and that he or she objects to the court’s Order of Referral.

2. If no objection is filed to the order within fourteen (14) days, the parties will participate in an orientation session, which will be conducted by the certified mediator. If a date and time for the orientation session is not already provided, the mediator will contact the parties to schedule this orientation session within thirty (30) days of entry of the order. If the mediator does not have phone numbers with which to contact the parties, it is the parties’ responsibility to contact the mediator to schedule the orientation session.

3. Referral to the dispute resolution orientation session has no impact on the docketing procedures followed by this court and this case either has been or will be set for trial in accordance with normal docketing procedures.

4. Attorneys for any party may be present at the dispute resolution orientation session.

5. After the orientation session, further participation in a dispute resolution proceeding shall be by consent of all parties. The decision to proceed shall be made at the close of the orientation session or no more than ten (10) days after the orientation session.

6. Parties have the option of selecting a mediator from the Directory of Certified Mediators, which is available on the Supreme Court home page (www.courts.state.va.us) or from the clerk’s office where the matter is pending, and paying a fee for mediation services, or continuing with the mediator appointed by the court to conduct the dispute resolution orientation session.

7. If the parties continue with the certified mediator appointed by the court to conduct the orientation session, the mediation will be conducted at no cost to the parties. The mediator will be compensated $100 per court appointment to handle the case(s) that are listed on the Order of Referral. The court appointment may include more than one petition/court case involving the same family and more than one session.

8. Regardless of the method of resolution selected by the parties, the case will proceed along the same time line as if the referral to the dispute resolution proceeding had never occurred. Every effort should be made for the mediation to be completed before the set trial date. In unusual circumstances, if the mediation cannot be completed before the trial date, the parties may be required to request that the court grant a continuance to allow them to complete the mediation process.

9. Upon conclusion of the mediation, the mediator must complete and submit to the court the Mediator Report located on the bottom of the Order of Referral and the DC-40 invoice form. The court will not process payment until all forms are submitted.

10. Mediators must provide parties with Client Evaluations at the conclusion of each court-referred mediation. These Client Evaluations may be submitted by either the mediator or parties directly to the Office of the Executive Secretary of the Supreme Court of Virginia.

http://www.courts.state.va.us/

Form DC-605 ORDER OF REFERRAL TO PARENT Form DC-605 EDUCATION SEMINAR


Using This Form

1. Copies


b. Second copy – to parent.

c. Third copy – to parent.

2. Prepared by clerk and signed by judge.

3. Attachments – none.

4. Preparation details

The parties to any proceeding that involves custody, visitation or support must provide proof to the court that they attended a parent education seminar. This order may be used to order the parties to attend a parent education seminar, if the court so desires.


ORDER OF REFERRAL TO PARENT EDUCATION SEMINAR Commonwealth of Virginia VA. CODE §§ 16.1-278.15, 20-103 Case No. ....................................................................................

[ ] Circuit Court ........................................................................................................................... [ ] Juvenile and Domestic Relations District Court ........................................................................................................................... v. ........................................................................................................................... In re: ............................................................................................................................................ ....................................................................................... JUVENILE DATE OF BIRTH [ ] ...................................................................................................................... and ..........................................................................................................................,

parties to a proceeding in which custody, visitation, or support of a child is at issue, are ordered to attend and complete an educational seminar or other like program conducted by a qualified person or organization approved by the court, on the effects of separation or divorce on minor children, parenting responsibilities, options for conflict resolution, and financial responsibilities

by ....................................................................................... . DATE

[ ] although the issue of custody, visitation or support is not contested, the following good cause exists to order the parties to the parent education seminar: ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. Based on the party’s ability to pay, each party shall be responsible for paying a fee of no more than $50.00 (fifty dollars) for the seminar. The fee is payable to the program. Other than statements or admissions by a party admitting criminal activity or child abuse or neglect, no statement by a party in such seminar or program shall be admissible into evidence in any subsequent proceedings. A list of parent education providers approved by this court is available at www.courts.state.va.us or from the clerk’s office where the matter is pending.

[ ] ...................................................................................................................... and ...........................................................................................................................

are exempt from attendance at the parent education seminar for good cause shown as follows: ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................

....................................................................................... _____________________________________________________________ DATE JUDGE

1

2

3

4 5

6

7

8

9

10

11 12

Form DC-605 ORDER OF REFERRAL TO PARENT Form DC-605 EDUCATION SEMINAR


Data Elements


2. Jurisdiction.

3. Style of the case when contested custody or visitation is present in such case.

4. Juvenile’s name.

5. Date of birth of juvenile.

6. Name(s) of person being ordered to attend and complete a parent education seminar. If only one person is required to attend, strike through the other line.

7. Date by which the persons must attend the seminar.

8. Check box and describe good cause for ordering parties to an uncontested custody, visitation or support case to parent education seminar.

9. Name(s) of persons exempted from attending and completing a parent education seminar. If only one person is exempted, strike through the other line.

10. Insert the facts that constitute good cause for exempting the person(s) from attending the parent education seminar.

11. Date the judge signed the order.

12. Judge’s signature.

Form DC-606 AFFIDAVIT IN SUPPORT OF APPLICATION FOR Form DC-606 PROCEEDING IN CUSTODY OR VISITATION CASE WITHOUT PAYMENT OF FILING FEES

DISTRICT COURT MANUAL FORMS VOLUME DECEMBER 2007

Using This Form

1. Copies

a. Original copy – to court.

2. Prepared by person requesting that he or she be allowed to proceed with a custody visitation case without paying the filing fees.

3. Possible attachments –

a. The court may request proof of income or expenses prior to ruling on the

application.


a. This form must be signed under oath and acknowledged by a notary, the intake officer of a clerk or deputy clerk.

b. If the petitioner went to the Intake Officer to petition for custody and/or visitation,

this document should be filed with the clerk’s office within 90 days of the petitioner receiving the completed documents from the Intake Officer.

c. If the court denies this application, the petitioner must pay the fees within 90

days.

AFFIDAVIT IN SUPPORT OF APPLICATION FOR PROCEEDING IN CUSTODY OR VISITATION CASE WITHOUT PAYMENT OF FILING FEES Commonwealth of Virginia VA. CODE § 16.1-69.48:5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Circuit Court [ ] Juvenile and Domestic Relations District Court

In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

The undersigned applicant requests the court to permit the applicant to proceed with a custody or visitation proceeding in this court without the payment of filing fees. In support of this application, the applicant states that the following information is true:

2

1. The undersigned applicant is a Virginia resident. 2. The following financial information applies to the applicant: a. Receiving public assistance [ ] No [ ] Yes-See items checked below [ ] Medicaid [ ] Supplemental security income [ ] TANF [ ] Food stamps

3

b. Take-home pay $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . per [ ] week [ ] every second week [ ] twice a month [ ] month

4

c. Other income, if any (specify sources and amounts): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 d. Assets Cash on hand $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bank accounts $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

7 e. Exceptional Expenses (Total Exceptional Expenses of Family)

Medical Expenses (List only unusual and continuing expenses) $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Court-ordered support payments/alimony $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Child Care payments $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other (Describe on reverse) $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

9

10

11


3. Other information a. The number of people for whom the applicant provides support is: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 b. The number of persons residing with the applicant is: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________________________________________________ DATE SIGNATURE – APPLICANT

14

15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NAME OF APPLICANT

16 Acknowledged, subscribed and sworn to before me this day:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER

17

18

FOR NOTARY PUBLIC’S USE ONLY:

State of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] City [ ] County of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acknowledged, subscribed and sworn to before me this . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________ NOTARY REGISTRATION NUMBER NOTARY PUBLIC (My commission expires: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )

19

ORDER The request to proceed without payment of filing fees is [ ] granted [ ] denied.

20

If this application is denied, the case will not be set for hearing until the applicable fee is paid to the clerk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________________________________________________ DATE JUDGE

21

22

Form DC-606 AFFIDAVIT IN SUPPORT OF APPLICATION FOR Form DC-606 PROCEEDING IN CUSTODY OR VISITATION CASE WITHOUT PAYMENT OF FILING FEES


Data Elements

1. Court name. Check the box for the type of court.

2. Style of case.

3. Check the applicable “no” or “yes” box to indicate whether the applicant is receiving public assistance. If yes is checked, check the box(es) that corresponds to the assistance received.

4. Insert the amount of take-home pay. Check the applicable box to indicate how often this amount is received.

5. Insert other sources of income and the amount received.

6. Insert the amount of cash the applicant has on hand.

7. Insert the amount of money in the applicant’s bank accounts.

8. Insert the amount of unusual and continuing medical expenses.

9. Insert the amount of any court-ordered support the applicant pays.

10. Insert the amount of any childcare payments the applicant makes.

11. Insert that amount of any other continuing expenses the applicant must pay and describe those expenses on the reverse of the form.

12. Indicate the number of people the applicant supports.

13. Indicate the number of people who reside with the applicant.

14. Date the affidavit is signed.

15. Signature of applicant.

16. Print the name of the applicant.

17. Date the signature of the applicant is acknowledged.

18. Signature of person acknowledging the above signature. Check the applicable box under the signature line.

19. If acknowledgement taken by a notary public, all enclosed fields must be completed including notary’s registration number and commission expiration date.

20. Check the applicable box to indicate whether the application has been granted or denied.

21. Date on which the order was signed.

22. Signature of judge.

Form DC-610 PETITION FOR SUPPORT (CIVIL) Page: 1



a. Original – to court. b. First copy – to respondent.


d. Other copies as dictated by local practice.

2. Prepared by petitioner; acknowledged by clerk, deputy clerk, intake officer or notary public. 3. Attachments – Form DC-510, SUMMONS. 4. Preparation details

a. Use this form when support is sought in civil-type proceedings under § 16.1-241(A)(3). Use form DC-612, DESERTION/NON-SUPPORT PETITION (CRIMINAL) only if the petitioner can meet the burdens of proof in a criminal action under § 20-61 for desertion and/or non-support.

b. In completing Page 1, Data Element No. 10, it may be necessary to use a separate sheet to

list where the dependents reside if all do not reside together.

c. In completing Page 2, Data Element Nos. 13, 14 and 15, the provisions for combined child/spousal (unitary) support, both current and arrearages, should be used only when such amounts requested are based on a prior court order in which a combined child spousal (unitary) support award was made.

d. In completing Page 2, Data Element No. 22, petitioner should be requested to promptly

contact the Division of Child Support Enforcement (DCSE) to complete the application process if payment through the Virginia Department of Social Services is sought and the petitioner has not already contracted with DCSE for services.

e. Note that if a protective order has been issued or the petitioner alleges that there is a risk

of harm from the other party, the personal information in Data Element No. 4 on page one (except for name) should not be included on this form, but instead should be included on district court form, DC-621, NON-DISCLOSURE ADDENDUM.



..........................................................................................................................

RESIDENTIAL ADDRESS

.......................................................................................................................... MAILING ADDRESS IF DIFFERENT

Social Security No. ...................................................................................

Driver’s License No. and State ............................................................

Telephone No. (H) .................................. (W) .......................................

Date of Birth ............................................................................................... ..........................................................................................................................

EMPLOYER

.......................................................................................................................... EMPLOYER’S ADDRESS

..........................................................................................................................

PER

SON

TO

BE

SUM

MO

NED

and

resp

onde

nt

PETITION FOR SUPPORT (CIVIL) CASE NO. .................................................................................. Commonwealth of Virginia VA. CODE §§ 16.1-241(A)(3), 16.1-278.15, 20-88 DCSE ID NO. ........................................................................... (to be added if DCSE is involved in case)

.......................................................................................................................................................................... Juvenile and Domestic Relations District Court

........................................................................................................................... v. ........................................................................................................................... PETITIONER RESPONDENT ........................................................................................................................... RESIDENTIAL ADDRESS ........................................................................................................................... MAILING ADDRESS IF DIFFERENT

Social Security No. ...................................................................................

Driver’s License No. and State .............................................................

Telephone No. (H) .................................. (W) ......................................

Date of Birth ................................................................................................ ........................................................................................................................... EMPLOYER ........................................................................................................................... EMPLOYER’S ADDRESS .................................................................................................................................................................

The petitioner’s information in the above box is provided on a separate sheet because [ ] a protective order has been issued or [ ] the petitioner alleges that the petitioner is at risk of physical or emotional harm from the other party.

The undersigned Petitioner respectfully represents to the Court:

2. [ ] That child custody has been adjudicated. If so, attach copy of the order. [ ] That an order concerning the support of the person(s) for whom the support is sought in this petition has been entered. (Attach most

recent court order.) [ ] That no other case for support for the below-named person(s) has been filed in any other court.

3. That the respondent has a legal duty to provide support and maintenance for the following persons: Name Social Security Number Date of Birth Relationship to Respondent

[ ] [ ] [ ] [ ]

who resides at [ ] petitioner’s address [ ] ......................................................................................................................................................................... 4. Division of Child Support Enforcement [ ] is [ ] is not involved in this case.

5. That support of the named persons who are the subject(s) of this petition is a subject of controversy or requires determination because:

................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................ FORM DC-610 (MASTER, PAGE ONE OF TWO) 07/10

1. [ ] That the parties have never been married; [ ] That there is a court order adjudicating the paternity of one or more of the subjects of this petition. If so, attach a copy of

the order. [ ] That the respondent and petitioner were lawfully married on ................................................. in ................................................................ DATE CITY/COUNTY AND STATE [ ] That the respondent and petitioner were divorced on .................................... in ................................................. (attach divorce decree). DATE CITY/COUNTY AND STATE [ ] Divorce pending in .............................................................................. CITY/COUNTY AND STATE

[ ] That the respondent is at least 18 years of age and is a child of the parent named below.

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2. DCSE ID number if Division of Child Support Enforcement has any involvement in the case, even if nothing more than payment processing. See Data Element No. 11.

3. Name of court in which petition is filed.

4. Name, residential address, mailing address if different, social security number, driver’s license number and state, home and work place telephone numbers, and date of birth of petitioner and name and address of petitioner’s employer. If petitioner has obtained a protective order against the other party or alleges to be at risk of harm from the other party, the information (other than name) should be placed on district court form DC-621, NON-DISCLOSURE ADDENDUM.

5. Respondent’s name, residential address, mailing address if different, social security number (if known), driver’s license number and state, home and work place telephone numbers (if known), and date of birth and name and address of respondent’s employer.

6. If petitioner requests that information in Data Element No. 4 (other than name) not be disclosed, check applicable box.

7. Check the appropriate boxes, and insert applicable information where appropriate.

8. Check the appropriate box or boxes.

9. Insert requested information regarding dependents for whom support is being claimed.

10. Check as applicable; if second box is checked, insert address where children reside. See Using This Form, 4.b.

11. Check the applicable box. See Data Element No. 2.

12. Description of the facts justifying the support claims.



PETITION FOR SUPPORT (CIVIL) Case No. ......................................................................................

6. A license, certificate, registration or other authorization to engage in a profession, business, trade, occupation, or recreational activity issued by the Commonwealth of Virginia is held by

TYPE OF LICENSE AGENCY GRANTING LICENSE LICENSE NO.

[ ] Respondent .......................................................... .............................................................................. .............................................................

[ ] Petitioner .......................................................... .............................................................................. .............................................................

7. A protective Order is currently in effect against the Respondent. [ ] Yes [ ] No. If yes, give name of court issuing the order, state and expiration date. ............................................................................................................................................................................................................................................................... COURT ISSUING ORDER STATE EXPIRATION DATE ............................................................................................................................................................................................................................................................... PERSON(S) PROTECTED BY THE ORDER The petitioner therefore prays that proper process be issued directing the respondent to appear and answer this petition in Court, and that the Court A. [ ] Make a finding in its Order that the Respondent is the parent of the children named in this petition (paternity has not been previously established). ............................................................................................................................................................................................................................................................... MOTHER’S NAME SSN MAIDEN NAME ............................................................................................................................................................................................................................................................... RESPONDENT’S NAME SSN RACE ............................................................................................................................................................................................................................................................... RESPONDENT’S DATE OF BIRTH PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)

B. [ ] Order the Respondent to furnish support as follows: [ ] Child support per guidelines [ ] Child support in the amount of $ ................................................................................................... per ....................................................................... TIME PERIOD

[ ] Spousal support in the amount of $ ............................................................................................... per ....................................................................... TIME PERIOD

[ ] Combined child and spousal support in the amount of $ .......................................................... per ....................................................................... TIME PERIOD

[ ] Continuing support for a child who is (i) severely and permanently mentally or physically disabled; (ii) unable to live independently and support himself and (iii) resides in the home of the parent seeking support.

[ ] Support for a parent in necessitous circumstances [ ] in the amount of $ ........................ per ..................... [ ] as determined by the court.

C. Enter an order or require the Respondent to enter into an agreement creating a wage assignment or income deduction to enforce any orders entered in the case as the responding court deems appropriate.

D. Order that all payments be made [ ] directly to the payee. [ ] to or through the Virginia Department of Social Services or its contractors. E. [ ] Provide in the order that Respondent furnish health insurance coverage, including dental and ophthalmologic (eye-related) services, if

available, for the dependents and for delivery of the documents necessary for the use of such coverage to the dependents. F. [ ] Provide in the order that the parents share the cost of any reasonable and necessary unreimbursed medical or dental expenses for each child

who is the subject of the obligation in proportion to their gross incomes. G. [ ] Require the Respondent to post a performance bond.

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............................................................................................................................................................................................................................................................... Petitioner further requests the granting of such other and further relief as the law provides. ...................................................................... _____________________________________________________________ DATE PETITIONER

The Petitioner appeared this date before the undersigned and, upon being duly sworn, made oath that the facts stated in the foregoing petition are true based on the Petitioner’s knowledge. ...................................................................... _____________________________________________________________ DATE [ ] CLERK [ ] INTAKE OFFICER FORM DC-610 (MASTER, PAGE TWO OF TWO) 07/14

FOR NOTARY PUBLIC’S USE ONLY: State of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] City [ ] County of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acknowledged, subscribed and sworn to before me this . . . . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________________________________________________________________ NOTARY REGISTRATION NUMBER NOTARY PUBLIC (My commission expires: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )

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Data Elements, page two 1. Court case number.

2. Check appropriate box if applicable. If a box is checked, identify professional, occupational or recreational license held.

3. Check applicable box and give information regarding order, if “yes” is checked.

4. Check if mother and father of children are not married and paternity has not been previously adjudicated.

5. Check if applicable.

6. Check if support is requested pursuant to the support guidelines.

7. Check if a specific amount of support is requested.

8. If Data Element No. 7 is checked, enter amount requested.

9. If Data Element No. 7 is checked, enter payment interval.

10. Check box if spousal support is requested.

11. If Data Element No. 10 is checked, then enter amount of spousal support requested.


13. Check if a combined child and spousal support is requested.



16. Check if applicable.

17. Check if support for a parent in necessitous circumstances is requested. See Data Element No. 7 for allegation that respondent is at least 18 years old and child of the named parent.

18. If Data Element No. 17 is checked, check this box if requesting a specific amount of support.



21. If Data Element No. 17 is checked, check this box if requesting that the court determine proper parental support payment amount.

22. Check how the petitioner wants payments handled.

23. Check if health insurance coverage is being sought.

24. Check if petitioner is requesting that medical and dental expenses be shared.

25. Check if petitioner is requesting that respondent must post performance bond.

26. Insert additional requested support relief.

27. Date of signing.

28. Signature of petitioner.

29. Date of acknowledgement.

30. Signature of person taking acknowledgement. Check the appropriate box below the signature line.

31. If acknowledgement taken by notary public, complete the box. Include notary public’s registration number, date and location of notarization, and expiration date of notary’s commission.

Form DC-611 PETITION FOR PROTECTIVE ORDER – Form DC-611 FAMILY ABUSE


Using This Form

1. Copies

a. Original – to court. b. First copy – to petitioner.

c. Second copy – to respondent.

d. Third copy – service copy.

2. Prepared by petitioner, acknowledged by intake officer, clerk or notary public. 3. Attachments

a. Affidavit of facts if petition not attested.


a. The petitioner must provide an affidavit of facts, either by a separate affidavit or by having the petition attested.

b. A temporary support order may be requested in conjunction with the protective

order. However, a support petition should be filed at the same time to request a final order of support. If custody or visitation is also sought, a separate form must also be filed.

c. Data Element Nos. 5 and 6 are critical since they will be used for service of orders

and the respondent is required to obey the orders only after the orders are served on him. Data Element No. 8 is critical since this information is necessary to register any protective order issued into the Virginia Criminal Information Network (VCIN) System.

d. The address and telephone number of the alleged abused person should not be

entered in the service box on page 2 of this form. This information is to be kept confidential. District court form DC-621, NONDISCLOSURE ADDENDUM, should be used to collect this information.


RESPONDENT’S DESCRIPTION RACE SEX BORN HT. WGT. EYES HAIR

MO. DAY YR. FT. IN.

SSN

PETITION FOR PROTECTIVE ORDER-FAMILY ABUSE Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonwealth of Virginia Va. Code §§ 16.1-241(M), 16.1-253.1, 16.1-279.1 Hearing Date and Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . To the Petitioner: Please provide your information on Form DC-621, NON-DISCLOSURE ADDENDUM.

The undersigned Petitioner respectfully represents to the Court that: 1. Petitioner and Respondent are family or household members because

[ ] Petitioner is the Respondent’s [ ] spouse [ ] former spouse [ ] parent, stepparent, child, stepchild, brother, sister, half-brother, half-sister,

grandparent, or grandchild, specifically . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law who resides in the same home with Respondent,

specifically, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Petitioner and Respondent [ ] have a child in common [ ] currently cohabit

[ ] cohabited within the previous 12 months. [ ] Petitioner and Respondent reside in the same home, and [ ] Petitioner is a child of a person Respondent cohabits with, or cohabited with within

the previous 12 months, or [ ] Petitioner is a person Respondent’s parent cohabits with, or cohabited with within the previous 12 months. 2. The Respondent is committing or, within a reasonable time, has committed the following acts of family abuse:

[ ] See accompanying affidavit.

[ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Other cases involving the Petitioner and Respondent [ ] have [ ] have not been filed in Virginia courts. 4. [ ] An Emergency Protective Order involving the

parties is in effect and was issued in the [ ] City [ ] County of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PETITIONER, THEREFORE, RESPECTFULLY REQUESTS that [ ] a preliminary protective order [ ] a protective order be issued and that such order impose the following conditions on the Respondent and such other conditions as the judge deems appropriate as allowed by law: [ ] Prohibiting further acts of family abuse or criminal offenses that result in injury to person or property. [ ] Prohibiting such contact with the Petitioner as the judge deems necessary for the health or safety of the Petitioner. [ ] Prohibiting such contact with the following family or household members as the judge deems necessary for their health and safety. (Please provide

on Form DC-621, NON-DISCLOSURE ADDENDUM, the date of birth, gender and race for each family or household member listed.)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME NAME NAME [ ] Granting the Petitioner possession of the premises occupied by Petitioner and Respondent to the exclusion of the Respondent. 2

This residence is located at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Prohibiting the Respondent from terminating [ ] requiring that the Respondent restore necessary utility service(s) to the premises indicated above

specifically, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UTILITY SERVICE(S) [ ] Granting the Petitioner temporary exclusive possession or use of a motor vehicle jointly owned by the parties or owned by the

Petitioner alone, described as follows: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Prohibiting the Respondent from terminating the [ ] insurance [ ] registration [ ] taxes on this motor vehicle. [ ] Requiring the Respondent to maintain the [ ] insurance [ ] registration [ ] taxes for this motor vehicle.

[ ] Requiring that the Respondent provide suitable alternative housing for the Petitioner [ ] and other family or household members [ ] and requiring the Respondent to pay deposit(s) to connect or restore necessary utility service(s) in the alternative housing, specifically,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UTILITY SERVICE(S) [ ] Granting temporary custody or visitation of a minor child or children to Petitioner (UCCJEA affidavit attached). (PROTECTIVE ORDER only.) [ ] Provide temporary support for minor children. [ ] Granting the Petitioner possession of the companion animal described as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME/TYPE

[ ] Other relief necessary for protection: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________________________________________________________________________________ DATE PETITIONER

___________________________________________ by ______________________________________________________ ATTORNEY’S ADDRESS AND TELEPHONE NUMBER PETITIONER’S ATTORNEY (When attested, this Petition shall also be an affidavit of the facts as stated in the Petition.) Sworn to/affirmed and signed before me this day.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________ DATE [ ] INTAKE OFFICER [ ] CLERK

FOR NOTARY PUBLIC’S USE ONLY: State of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] City [ ] County of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledged, subscribed and sworn to before me this . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________________________________________________________________ NOTARY REGISTRATION NUMBER NOTARY PUBLIC (My commission expires: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )

SUMMONS FOR HEARING: TO THE RESPONDENT: You are hereby summoned to

appear in this Court on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . ________________________________________ [ ] CLERK [ ] DEPUTY CLERK

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juvenile and Domestic Relations District Court

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PETITIONER RESPONDENT

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESPONDENT’S ADDRESS/LOCATION

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(H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (W) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESPONDENT’S TELEPHONE NUMBER

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1. Court case number. 2. Hearing date and time.

3. Court name.

4. Petitioner’s name.

5. Respondent’s name.

6. Respondent’s address or location

where respondent may be found.

7. Respondent’s home telephone number and work telephone number.

8. Insert identifying information for

respondent, if known.

9. Check appropriate box to indicate how petitioner and respondent are family or household members and insert specific nature of relationship, as applicable.

10. Check appropriate box and, if

applicable, insert facts. See Using This Form, 4.a.

11. Check applicable box to indicate

whether or not other cases involving the parties have been filed in Virginia courts.

12. Check this box if an emergency

protective order involving the parties is in effect, and insert name of issuing jurisdiction and date of order.

13. Check the appropriate box(es) and, if

applicable, insert other relief sought. See Using This Form, 4.b.

14. Indicate name(s) of other family or household member(s) for whom petitioner is seeking protection, if applicable.


16. Signature of petitioner. If filed by

petitioner’s attorney, print or type in petitioner’s name.

17. Attorney’s address and telephone

number if filed by an attorney.

18. Attorney’s signature if filed by an attorney.

19. Date of attestation.

20. Signature of person taking the

attestation. Check the appropriate box below the signature line.

21. If attestation taken by notary public,

all enclosed fields must be completed including notary’s registration number and commission expiration date.

22. Date of hearing on petition.

23. Time of hearing on petition.

24. Signature of clerk issuing summons.

Check appropriate box below signature line indicating title.


Case No. ............................................................................................... RETURNS: Each person was served according to law, as indicated below, unless not found.

“Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the

person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person.

“Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury.

RESPONDENT:

NAME ................................................................................................................

............................................................................................................................

ADDRESS .........................................................................................................

............................................................................................................................

[ ] PERSONAL SERVICE TELEPHONE NO. .....................................

[ ] NOT FOUND

______________________________________________________________ SERVING OFFICER

for ___________________________________________________________ ............................................................................................................................

DATE AND TIME

Respondent’s Description (for VCIN)

RACE ............................................ SEX ................................................

DOB ...................................................................................................................

HGT .............................................. WGT ...............................................

EYES ............................................ HAIR ..............................................

SSN ....................................................................................................................

Telephone No. ....................................................................................................

Relationship to Petitioner/Plaintiff .....................................................................

Distinguishing features .......................................................................................

PETITIONER: (See form DC-621, NON-DISCLOSURE ADDENDUM)

NAME ........................................................................................................

.....................................................................................................................

[ ] PERSONAL SERVICE

[ ] NOT FOUND

__________________________________________________________ SERVING OFFICER

for _______________________________________________________

..................................................................................................................... DATE AND TIME

[ ] Copy delivered to ..................................................................................................................... ..................................................................................................................... by ...............................................................................................................

TITLE __________________________________________________________

SIGNATURE .................................................... DATE

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2. Respondent’s name. 3. Respondent’s address and telephone number.

4. Indicate either personal service or “not found.”

5. Name of serving officer.

6. Jurisdiction. Name of sheriff if served by deputy sheriff.

7. Date and time of service.

8. Enter respondent’s description to be entered into VCIN.


10. Signature of serving officer.

11. Jurisdiction. Name of sheriff if served by deputy sheriff.

12. Date and time of service.

13. Indicate if, instead of service, a copy of the petition was delivered to petitioner and insert

petitioner’s name.

14. Title of person delivering copy to petitioner.

15. Signature of person delivery copy of petition to petitioner.

16. Date of delivery.

Form DC-612 DESERTION/NON-SUPPORT PETITION Form DC-612 (Criminal)


Using This Form

1. Copies


b. First copy – to defendant.


d. Other copies as dictated by local practice.

2. Prepared by petitioner; acknowledged by clerk, deputy clerk, intake officer or notary public.

3. Attachments

a. Form DC-314, WARRANT OF ARREST (STATE MISDEMEANOR) and form DC-614, AFFIDAVIT – DESERTION AND NON-SUPPORT, if defendant arrested under Va. Code § 20-70 and the petition is issued prior to the issuance of the warrant.

b. Form DC-319, SUMMONS for all other service of process.


a. This petition is used to initiate criminal proceedings under Title 20. Use form DC-610, PETITION FOR SUPPORT (CIVIL), in all other support actions brought in a juvenile and domestic relations district court under Va. Code § 16.1-241(A)(3).

b. In completing Page 1, Data Element No. 10, check the applicable box in each pair regarding custody and parentage adjudication regardless of the marital status of the parties.

c. In completing Page 1, Data Element No. 10, it may be necessary to use a separate sheet to list where the dependents reside if all do not reside together.

d. In completing page 2, Data Element Nos. 7 and 10, the provisions for combined child/spousal (unitary support, both current and arrearages, should be used only when such amounts requested are based on a prior court order in which a combined child/spousal (unitary) support award was made.

e. In completing Page 2, Data Element No. 11, petitioner should be requested to promptly contact the Division of Child Support Enforcement to complete the application process if payment through the Virginia Department of Social Services is sought.


DESERTION/NON-SUPPORT PETITION (Criminal) CASE NO. ................................................................................... Commonwealth of Virginia VA. CODE §20-61 DCSE ID No. ............................................................................ (to be added if DCSE is involved in case) .............................................................................................................................................................. Juvenile and Domestic Relations District Court ........................................................................................................................ v. ........................................................................................................................ PETITIONER RESPONDENT ........................................................................................................................ ........................................................................................................................ RESIDENTIAL ADDRESS RESIDENTIAL ADDRESS ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ MAILING ADDRESS IF DIFFERENT MAILING ADDRESS IF DIFFERENT Social Security No. ..................................................................................... Social Security No. ..................................................................................... Driver’s License No. and State ................................................................ Driver’s License No. and State ................................................................ Telephone No. (H) ....................................... (W) ..................................... Telephone No. (H) ....................................... (W) ..................................... Date of Birth ............................................................................................... Date of Birth ............................................................................................... ........................................................................................................................ ........................................................................................................................ EMPLOYER EMPLOYER ........................................................................................................................ ........................................................................................................................ EMPLOYER’S ADDRESS EMPLOYER’S ADDRESS ........................................................................................................................ ........................................................................................................................ [ ] Petitioner’s Address not to be disclosed The undersigned petitioner respectfully represents to the Court: 1. [ ] That the parties have never been married;

[ ] That the defendant and petitioner were lawfully married on .............................................. in .......................................................................... DATE CITY/COUNTY AND STATE

2. [ ] That within the past .............................................................................................................................................................................................................. TIME PERIOD [ ] That on or about ..................................................................................................................................................................................................................... DATE

the said defendant did unlawfully and without just cause, [ ] desert and/or [ ] willfully neglect and refuse and fail to provide for the support and maintenance of [ ] his or her spouse and the following children under the age of eighteen years: Name Date of Birth

Prior Adjudications as to Custody Parentage

[ ] ........................................................................................................................................................... [ ] Yes [ ] No [ ] Yes [ ] No [ ] ........................................................................................................................................................... [ ] Yes [ ] No [ ] Yes [ ] No [ ] .......................................................................................................................................................... [ ] Yes [ ] No [ ] Yes [ ] No [ ] ........................................................................................................................................................... [ ] Yes [ ] No [ ] Yes [ ] No Who resides at [ ] petitioner’s address [ ] .......................................................................... (Check if a child is over eighteen years of age and disabled or otherwise incapable of earning a living.) [ ] his or her [ ] mother [ ] father ...................................................................................... such parent being incapacitated and unable to maintain herself or himself, such spouse, child or parent being then and there in necessitous circumstances.

3. [ ] That no other case for support involving petitioner and respondent has been filed in any other court.

[ ] Attached is/are support order(s) for the above named person(s) for whom support is being sought. 4. Division of Child Support Enforcement [ ] is [ ] is not involved in this case. 5. That this court has jurisdiction by reason of the fact that:

[ ] At the time of desertion, such spouse, child, children, or parent were residents of this jurisdiction; (or) [ ] Such spouse, child, children, or parent were residents of this jurisdiction in necessitous condition and have remained here in such condition with the knowledge and acquiescence of the defendant; (or) [ ] The defendant is now and may be found within the jurisdiction of this Court.

6. That the facts and circumstances of this case are as follows: ......................................................................................................................................... ............................................................................................................................................................................................................................................................... ...............................................................................................................................................................................................................................................................

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1. Court case number. 2. DCSE ID number if Division of Child Support Enforcement has any involvement in the

case, even if nothing more than processing payments. See Data Element No. 2. 3. Name of court in which petition is filed. 4. Name, residential address, mailing address if different, social security number, driver’s

license number, home and workplace telephone numbers, birth date of petitioner and name and address of petitioner’s employer.

5. Respondent’s name, residential address, mailing address if different, social security

number (if known) driver’s license number, home and workplace telephone number (if known), birth date (if known) and name and address of respondent’s employer.

6. Check box if applicable. 7. Check the appropriate box; insert applicable information if last box is checked. 8. Check the applicable box and complete the line to describe when the event described in

Data Element No. 8 occurred. 9. Check the appropriate boxes to describe the alleged offense. 10. Check the applicable boxes and insert requested information regarding dependents for

whom support is being claimed. Check applicable box in each pair of boxes regarding custody and parentage adjudications and the address of the dependents. See Using This Form, 4.c. and 4.d..

11. Check the applicable box. 12. Check the applicable box. See Data Element No. 2. 13. Check appropriate box(es) to show why this case should be brought in the court described

in Data Element No. 3. 14. Describe the facts justifying the support claim.

FORM DC-612 (MASTER, PAGE 2 OF 2) 07/14

7. An Order of Protection is currently in effect against the defendant [ ] yes [ ] no. If yes, give name of court issuing the order, state and expiration date. .......................................................................................... ................................................................ .................................................................................. COURT ISSUING ORDER STATE EXPIRATION DATE . .......................................................................................... PERSONS PROTECTED BY THE ORDER

Wherefore, your petitioner prays that proper process may issue, that the Court may make all proper and necessary inquiries into the matters set out above and find that the defendant is guilty of desertion and/or willful neglect and refusal and failure to provide for the support and maintenance of the dependents described in the petition, and that the Court

A. [ ] Make a finding in its Order that the Defendant is the father of the children named in this petition (paternity has not been previously established).

B. [ ] Order the defendant to furnish support as follows: $ ................................................................................. per ............................................................ for child support divided thusly: TYPE OF TIME PERIOD

[ ] $ ............................................... divided equally among the above named children, or; [ ] $ .................................................................................................................................. $ .................................................................................... per ..................................................................... for spousal support and, in the Order,

specifically allocate between child and spousal support TYPE OF TIME PERIOD

OR ..

$ ............................................................................................. per ......................................................... for combined child/spousal (unitary) support TYPE OF TIME PERIOD or such other amount as the Court deems to be appropriate which is needed for support of the above listed dependents. C. [ ] Order the Defendant to make reimbursements or arrearages which subsequently accrue, with the Defendant to pay a reasonable

amount on a periodic basis: [ ] $ ............................................ payable for child support as of ....................................................... accruing at a rate of $ .......................................... per ........................................................................ TYPE OF TIME PERIOD [ ] $ ............................................ payable for child support as of ....................................................... accruing at a rate of $ ........................................... per ........................................................................ TYPE OF TIME PERIOD and, in the Order, specifically allocate between child and spousal arrearage.

OR . [ ] $ ............................................ for combined child/spousal (unitary) support as of ................................................................................................... accruing at a rate of $ ................................................... per ........................................................... TYPE OF TIME PERIOD

D. Enter an order or require the Defendant to enter into an agreement creating a wage assignment to enforce any orders entered in the case as the responding court deems appropriate.

E. Order that all payments be made [ ] directly to the payee [ ] to or through the Virginia Department of Social Services or its contractors.

F. [ ] Provide in the order that the Defendant provide health insurance coverage, including dental and ophthalmologic (eye-related) services, if available, for the dependents and deliver the documents necessary for the use of such coverage to the dependents.

G. [ ] Provide in the order that the parents share the cost of any reasonable and necessary unreimbursed medical or dental expenses for each child who is the subject of the obligation in proportion to their gross incomes.

H. [ ] Require the defendant to post a performance bond. I. ............................................................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................... Petitioner further requests the granting of such other and further relief as the law provides. Written testimony and other documentation in support of this petition are attached and incorporated herein and made a part of this Petition. ......................................................................................................... __________________________________________________________________ DATE PETITIONER The Petitioner appeared this date before the undersigned and, upon being duly sworn, made oath that the facts stated in the foregoing petition are true based on the Petitioner’s knowledge except as to those matters which are stated to be alleged on information and belief, to which the Petitioner believes such matters to be true.

......................................................................................................... __________________________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER

FOR NOTARY PUBLIC’S USE ONLY

State of ................................................................................. [ ] City [ ] County of ........................................................................................ Acknowledged, subscribed and sworn to before me this ..................... day of ......................................................................... , 20 ..................

.......................................................................... ________________________________________________ NOTARY REGISTRATION NUMBER NOTARY PUBLIC (My commission expires: ....................... )

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1. Check applicable box and enter information if answer is “yes.”

2. Check of mother and father are not married and paternity has not been previously adjudicated.

3. Check if applicable (for current support). See Using This Form, 4.d..

4. If Data Element No. 3 is checked and child support is requested, insert total amount of child support and payment interval.

5. If child support is requested, check the applicable box and complete the applicable lines to show

allocation of child support.

6. If Data Element No. 3 is checked and spousal support is requested, insert the amount and payment interval.

7. If Data Element No. 3 is checked and unitary child/spousal support is requested, insert amount of

support and payment interval.

8. Check if applicable (for arrearages). See Using This Form, 4.d..

9. If Data Element No. 8 is checked, check the applicable boxes if separate amounts for child support and for spousal support are awarded.

10. If Data Element No. 8 is checked and unitary child/spousal support was awarded, check this box

and insert the appropriate data.

11. Check how petitioner wants payment handled. See Using This Form, 4.e..

12. Check if this type of relief is being sought.

13. Check this box if the complainant requests that medical and dental costs be shared.

14. Check if this type of relief is being sought.

15. Insert additional requested support relief.



18. Date of acknowledgment.

19. Signature of person taking acknowledgment. Check the appropriate box below the signature line.

20. If acknowledgement taken by notary public, all enclosed fields must be completed including notary’s registration number and commission expiration date.

Form DC-615 Form DC-615

RESPONDENT'S REQUEST FOR INCOME DEDUCTION ORDER

Using This Revisable PDF Form

1. Copies

a. Original - to court.

b. First copy - to respondent.

2. Prepared and signed by respondent.

3. Attachments

a. Form DC-645(a), INCOME DEDUCTION ORDER FOR SUPPORT, if issued.

4. Preparation Details

a. The information in Data Element No. 13 is used to determine the maximumpercentage of disposable earnings which may be withheld pursuant to VirginiaCode § 34-29.

b. In Data Element No. 15, respondent may request a specific amount to reducearrearages if the order does not provide for periodic payment on arrearages. Therespondent may request the same or a larger amount if the order provides forperiodic payment to reduce arrearages.

c. In Data Element No. 17, check “same as above” if normal pay interval is same asData Element Nos. 8 and 9. Otherwise check “different from above...” and thencheck the appropriate box below that line and fill in the appropriate line(s). Usethis information in completing the pay interval provisions in the Form DC-645(a),INCOME DEDUCTION ORDER FOR SUPPORT, and the EMPLOYER’S INCOMEDEDUCTION ORDER FOR SUPPORT, form DC-645(b).

d. Data Element No. 12 - one of the two boxes must be checked to show whether thededuction is to be applied first to support or to health care coverage if the amountdeducted is insufficient to cover both the support amount and the health carecoverage cost.

I am also ordered to provide health care coverage for the following persons:STATUS (check applicable box)

NAME Dependent Current FormerChild Spouse Spouse Payment Priority

1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ž Support2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ž Health care3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . coverage4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RESPONDENT’S REQUEST FOR INCOME DEDUCTION ORDER Case No.: . . . . . . . . . . . . . . . . . . . . . . .Commonwealth of Virginia VA. CODE § 20-79.1 DCSE No.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juvenile and Domestic Relations District Court

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PETITIONER RESPONDENT

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ADDRESS ADDRESS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER

I, the undersigned Respondent, state that the following is my court-ordered periodic support payment in this case:

Žweekly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Žbi-weekly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Žsemi-monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Žmonthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ž . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OTHER PAY INTERVAL AND REGULAR PAY DATES

} regular pay dates

$ . . . . . . . . . . . . . . . . . . . . . . . . current supportpayable:

$ . . . . . . . . . . . . . . . . . . . . . . . . . . applied to arrearages}

Support of other dependents:

Ž I am not providing support to another spouse or another dependent child other than such spouse and/or dependent child(ren) for whom supportis to be provided through this case.

Ž I am providing support to these other spouse(s) and/or child(ren) for whom no support is provided through this case: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I hereby request this court to enter an Income Deduction Order for the withholding from my income of:$ . . . . . . . . . . . . . . . current support $ . . . . . . . . . . . . . . . . to be applied to arrearagesMy employers are:1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NAME NAME

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ADDRESS ADDRESS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .whose normal pay dates are

Žsame as above Ž different from above in that I am paidŽ weekly Ž semi-monthlyŽ bi-weekly Ž monthly Ž . . . . . . . . . . . . . . . . . . . . . . .with paydays being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NORMAL PAYDAY

I also waive notice of a hearing on the matter. . . . . . . . . . . . . . . . . . . . . . . . . _______________________________________________DATE RESPONDENT

FORM DC-615 (MASTER) 7/98 PC

whose normal pay dates are

Žsame as above Ž different from above in that I am paidŽ weekly Ž semi-monthlyŽ bi-weekly Ž monthly Ž . . . . . . . . . . . . . . . . . . . . . . .with paydays being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NORMAL PAYDAY

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Form DC-615 Form DC-615

RESPONDENT'S REQUEST FOR INCOME DEDUCTION ORDER

Data Elements


2. Division of Child Support Enforcement Case I.D. number.

3. Court name.

4. Name and (if known) residential address and social security number of petitioner.

5. Name, residential address and social security number of respondent.

6. Total amount of court-ordered periodic current support payment (if any).

7. Total amount of court-ordered periodic payment to reduce arrearages (if any).

8. Check appropriate box to show scheduled frequency of support payments.

9. Due dates for payments (examples: “each Friday,” “first and sixteenth of each month,”“fourth Monday of each month”).

10. Name of each person for whom the respondent has been ordered to provide health carecoverage.

11. For each person, check the applicable box to show the relation of such person to therespondent.

12. Check one of the two check boxes. See “Using this Form,” 4(d).

13. Check the appropriate box. If the second box is checked, insert the names of persons forwhom support is being provided. See “Using this Form,” 4(a).

14. Same as Data Element No. 6.

15. Same as Data Element No. 7 if court-ordered. See “Using this Form,” 4(b).

16. Name and address of employer(s).

17. Check the appropriate box for each employer and, if appropriate, fill in the appropriateblank(s). See “Using this Form,” 4(c).

18. Date of signing of stipulation.

19. Signature of respondent.

Form DC-616 ORDER OF TRANSFER Form DC-616


Using This Form

1. Copies

a. Original – to court where case is transferred (with case papers).

b. First copy – to transferor court's records.

c. Additional copies to parties in the case.

2. Prepared by clerk, signed by judge.

3. Attachments

a. Case papers going to court where case is transferred.


a. The transferor court should keep the first copy of the order in a new file as a replacement for the case file transferred in order to have a record of the transfer of the case. This replacement file should use the original case file number.

FORM DC-616 MASTER 10/11 ORDER OF TRANSFER Case No. .............................................................

ORDER OF TRANSFER Case No. ................................................................... Commonwealth of Virginia ......................................................................................................................................................... Juvenile and Domestic Relations District Court .................................................................................................................... In re/v ......................................................................................................................... PETITIONER [ ] RESPONDENT [ ] DEFENDANT [ ] JUVENILE .................................................................................................................... ......................................................................................................................... ADDRESS/LOCATION ADDRESS/LOCATION The [ ] respondent [ ] defendant [ ] juvenile was brought before this Court in conjunction with a certain petition, namely: ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................

Pursuant to the Code of Virginia, 1950, as amended, and

[ ] on its own motion,

[ ] on motion of ................................................................................................................................................................................................................................................................ this Court transfers this matter to the court of the city or county wherein the

for the following reasons: ....................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................ and the Court hereby ORDERS the transfer of this case and all legal and social records pertaining to this case to the ................................................................................................................................................................................................................................................................

NAME OF COURT for such further action or proceedings as it may deem proper and necessary. .................................................................................................................... ____________________________________________________________ DATE JUDGE

VA. CODE § 16.1-243 § 20-83.1 § 16.1-295

[ ] respondent

[ ] defendant

[ ] spouse

[ ] dependent child/juvenile

[ ] ...................................................................................

[ ] is present [ ] resides [ ] ..................................................................................................................

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1

Form DC-616 ORDER OF TRANSFER Form DC-616


Data Elements

1. Court case number. If form is clipped to file at top of page, put case number at bottom of page. Otherwise, put case number at top of page.

2. Court name.

3. Name and street address of petitioner.

4. Name and street address of respondent, defendant, or juvenile. Check the appropriate box under the line.

5. Description of allegations in petition.

6. Check the applicable box. Also name the party making the motion if not made by the court.

7. Check the boxes designating the basis for transferring venue. Check at least one type of party and at least one of the boxes on the right side and, if applicable, insert the fact which allows for transfer of venue.

8. State reason why transfer was made.

9. Name of court to which the case is transferred.

10. Date of entry of order.



Form DC-617 MOTION AND NOTICE OF PROPOSED INCOME Page: 1 DEDUCTION ORDER FOR SUPPORT

Using This Form

1. Copies


b. First copy - to respondent. See Using This Form, 4b.

c. Second copy - to payee (if initiated on the court’s own motion and both parties are not in court). See Using this Form, 4c.

2. Motion prepared by requesting party (See Using this Form, 4c, notice prepared by clerk). 3. Attachments - form DC-645(a), INCOME DEDUCTION ORDER FOR SUPPORT, if issued. 4. Preparation Details

a. This form must be used unless the respondent files a RESPONDENT’S REQUEST FOR INCOME DEDUCTION ORDER, form DC-615, or the parties are before the judge when an income deduction order is requested by a party or on the judge’s motion.

b. The respondent has only ten calendar days to file a written notice of contest to have a hearing on

the motion (Data Element No. 20, front); otherwise, an order must be entered as requested (Virginia Code ' 20-79.1(B)(2)). Also, if a notice of contest is filed, the hearing must be conducted within ten days from the filing of the request. Because of timeliness of service of process problems,

• The clerk should insert a pre-set hearing date in Data Element No. 21(front).

• a copy should be mailed to the party to be served unless the serving officer can get service

within the ten-day period.

c. If the request is initiated by someone other than the payee, the status of the signer should be shown below the signature line in Data Element No. 19; the payee’s name (if different from the petitioner) and residential address for service of process should be inserted only on the payee’s copy and the original copy. If served by different serving officers, an extra copy should be provided for return of service of process.

d. Data Elements Nos. 6 and 7 should be used in the INCOME DEDUCTION ORDER FOR SUPPORT,

form DC-645(a), and the EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, DC-645(b). if Data Elements Nos. 6 and 14 do not agree, convert the payment to conform to the information in Data Elements Nos. 6 and 7 by using the Payroll Conversion Table in IX of the DISTRICT COURT MANUAL.

e. The maximum percentage deductible from disposable income is determined by Va. Code § 34-

29(b1) based on:

• Whether any other dependants not covered by the order in the case are being supported by the respondent, and

• Whether total support payments are more than twelve weeks in arrears.



Using this Form, continued

The percentages are:

55% - other dependants, no arrearages over twelve weeks 55% - other dependants, arrearages over twelve weeks. 60% - no other dependants, no arrearages over twelve weeks 65% - no other dependants, arrearages over twelve weeks

f. Data Element No. 10 – one of the two boxes must be check to show whether the deduction is to be applied first to support or to health care coverage if the amount decided is insufficient to cover both the support amount and the health care coverage cost.

Form DC-617 MOTION AND NOTICE OF PROPOSED INCOME Page: 3 DEDUCTION ORDER FOR SUPPORT MOTION AND NOTICE OF PROPOSED Case No. .............. ....................................................... INCOME DEDUCTION ORDER FOR SUPPORT DCSE ID No. ............... ..........................................

1 2Commonwealth of Virginia VA. CODE § 20-79.1


Payment Priority

[ ] Support [ ] Health care

coverage

................................................................................................................................................................... Juvenile and Domestic Relations District Court

3

................................................................................................................................................................................................................................................................... ADDRESS

........................................................................................................................... v. .....................................................................................................................

4 PETITIONER RESPONDENT

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........................................................................................................................... ..................................................................................................................... SOCIAL SECURITY NUMBER ADDRESS

..................................................................................................................... MOTION: ..................................................................................................................... I request the court to enter an income deduction order which SOCIAL SECURITY NUMBER

contains the following terms: 1. Proposed Income Deduction Terms:

Pay interval:

[ ] weekly ................................................................................................ [ ] bi-weekly .......................................................................................... [ ] semi-monthly .................................................................................. regular pay dates [ ] monthly .............................................................................................. [ ] ....... ........................................................................................................

OTHER PAY INTERVAL AND REGULAR PAY DATES

The Respondent has also been ordered to provide health care coverage for the following persons:

STATUS (check applicable box) NAME Dependent Current Former

Child Spouse Spouse

1. .........................................................................................

2. .........................................................................................

3. .........................................................................................

4. .........................................................................................

5. .........................................................................................

6. .........................................................................................

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2. Proposed amount to be deducted each pay period:

$ ........................................... or ......................................... % of disposable income, whichever is less based on court-ordered

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payments of $ ........................................ per ................................... with $ ....................................... total unpaid payments.

12 13 14 15

3. Reason for proposed support income deduction order:

[ ] receipt of notice of arrearage in support payments [ ] court has found that there is an arrearage of an amount equal to one month’s support obligation

[ ] facts relevant in determining the likelihood of [ ] request of the obligor 16 payments in accordance with the support order [ ] Other: .............................................................................................................

4. ..........................................................................................................................................................................................................................................................

17EMPLOYER’S NAME

.......................................................................................................................................................................................................................................................... EMPLOYER’S ADDRESS

.............................................................................. __________________________________________________________________

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19 DATE PETITIONER

NOTICE TO THE RESPONDENT/OBLIGOR: Read this entire Notice (pages one and two) carefully. This motion is made pursuant to Virginia Code § 20-79.1. If you wish to contest this Motion, written notice must be filed in the clerk’s office by

.................................................................................................................................... for a hearing on ........................................................................................... FILING DEADLINE HEARING DATE

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....................................................................................... ___________________________________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK

22

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Data Elements, page one 1. Court case number. 2. Division of Child Support Enforcement case I.D. number 3. Court name. 4. Petitioner’s name and social security number. 5. Respondent’s name, residential address and social security number. 6. Check, and if appropriate, fill in the line regarding respondent’s pay interval. See “Using This

Form,” 4(d). 7. Insert description of respondent’s normal pay date, (such as “every Friday,” “first and sixteenth of

each month,” etc.). See “Using This Form,” 4(d). 8. Name of each person for whom the respondent has been ordered to provide health care coverage. 9. For each person, check the applicable box to show the relation of such person to the respondent. 10. Check one of the two check boxes. See “Using This Form,” 4(f). 11. Maximum amount proposed to be deducted during each pay period. 12. Maximum percentage which may be deducted per pay period from disposable income. See “Using

This Form,” 4(e). 13. Total court-ordered periodic support payments for current support and arrearages. 14. Court-ordered payment interval on support payments. See “Using This Form,” 4(d). 15. Total support arrearages. If none, insert “0.00.” 16. Check appropriate box(es) and, if appropriate, insert additional information. 17. Insert employer’s name and address where the employer can be served with process. 18. Date of signing of motion. 19. Signature of petitioner. See “Using This Form,” 4(c), if signed by someone other than the payee. 20. Date by which respondent must file notice of contest. See “Using This Form,” 4(b). 21. Insert pre-set hearing date if notice of contest is filed. See “Using This Form,” 4(b). 22. Date of signing of notice. 23. Signature of clerk or deputy clerk. Check appropriate box below the line.


TO THE RESPONDENT/OBLIGOR:

This notice is to advise you that this Court has been requested for the reason stated above to enter an order requiring all of your present and future employers to deduct support payments as described above from your income. This deduction will begin with the next regular pay interval for your income after your employers are served with an order.

You have ten (10) days from the date of issuance of this Notice to file in the clerk’s office of this court a written notice of contest of such proposed order. If no written notice of contest is filed, the court will enter such an order at the end of the ten (10) day filing period. If you file a written notice of contest,

— a hearing will be held and a decision made regarding the issuance of the Order and its contents within ten (10) days from the date that the Court receives your written notice of contest, unless good cause is shown for additional time, but not to exceed forty-five (45) days from your receipt of this notice, and

— only disputes as to mistakes of fact (error in the identity of the payor or the amount of current support or arrearage) will be heard. Alleged inability to pay is not a grounds for contest.

— payment of overdue support upon receipt of the notice shall not be the sole basis for not implementing withholding.

The order will state that the deduction will start with the regular pay period for your income after you employer is served with an order. Your employer will be told the names of the petitioner, the court file number, the DCSE ID number (if any), your name, address, and social security number, and the terms of the periodic support payment, and where to send payments. The employer will also be told:

— the maximum amount which can be withheld from your income,

— that the order is binding on the employer until further notice sent by the court is received by the employer,

— that the order requires income deductions for support to be paid before any other liens created under state law except that, when judicial or administrative income deduction orders for support have been previously served on the employer, the employer must prorate the amount withheld from your check among all income deduction orders of support based upon the current amounts due, with any remaining income prorated among the orders for accrued arrearages, if any,

— that deductions are to be made on your regular payday and sent that date to the Virginia Department of Social Services and how to send such payments,

— of his liability for failing to honor the order or for taking retaliatory action against you because of such order,

— that the employer and respondent must notify the Virginia Department of Social Services when your employment terminates, and give your home address and the name and address of your new employer,

— that the employer may deduct an additional fee of $5.00 for each time that the employer deducts money or answers in writing that the employer was legally unable to makes such deductions,

— how the employer should respond if the order contains erroneous information, and

— the statutory authorization for such order.

SERVICE OF PROCESS ON RESPONDENT:

[ ] Personal service 1

Being unable to make personal service, a copy was delivered in the following manner:

[ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode or party named above after giving information of its purport. (List name, age of recipient and relation to party named above.)

..........................................................................................................................................................................................................................................................


[ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above.

(Other authorized recipient not found.) [ ] Certified mail. [ ] Facsimile service on employer to deliver to respondent.

2 3

[ ] Not found. 4

............................................... _____________________________________________ for ________________________________________ DATE SERVING OFFICER

5

6

7 FORM DC-617 (MASTER, PAGE TWO OF TWO) 4/06




1. Serving officer to check this box if personal service obtained. 2. Serving officer to check the appropriate box to designate type of substituted service. 3. If served by leaving a copy with a family member aged 16 or older, check appropriate box

and insert required information. 4. Serving officer to check this box if unable to serve process. 5. Date of signature. 6. Signature of serving officer. 7. Name of sheriff if served by deputy sheriff.

Form DC-618 REQUEST FOR CONFIDENTIALITY - CIVIL Form DC-618

Using This Form

This form is completed when a party involved in a custody or support proceeding wishes

to request the court not to release any information regarding the party. The party must meet the requirements under which a person may request that their identifying information be kept confidential. Please see the statements following “custody proceeding” and/or “support proceeding” to determine if you meet the requirements.

Once the request is received, all documents containing the protected information must be kept sealed in a manila envelope in the case file and will be kept confidential.

DISTRICT COURT FORMS JULY 2005

REQUEST FOR CONFIDENTIALITY –– CIVIL Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Commonwealth of Virginia Va. Code §§ 20-60.3; 20-146.20E

[ ] Circuit Court TO: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Juvenile and Domestic Relations District Court

2 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

[ ] Custody Proceeding: I request that the above-named court(s) not disclose, release or allow to be examined any identifying information about me because my health, safety or liberty would be jeopardized by the disclosure of such information. 5

[ ] Support Proceeding: I request that the above-named court(s) not disclose, release or allow to be examined any information about me because [ ] a protective order has been issued [ ] I am at risk of physical or emotional harm from the other party.

SHERIFF/PROCESS SERVER: THE INFORMATION CONTAINED IN THIS DOCUMENT IS CONFIDENTIAL AND MAY NOT BE DISCLOSED TO THE PARTIES OR TO THE PUBLIC.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ADDRESS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE OF BIRTH SOCIAL SECURITY NUMBER

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMPLOYER NAME AND ADDRESS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER VIRGINIA DRIVER’S LICENSE NUMBER

NOTICE: When a party to a custody proceeding requests that information be kept confidential, this information shall not be released except by order of the court. In support cases where a person requests that information be kept confidential, the information should not be released except by order of the court.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________________________________________________ 7 8 DATE OF REQUEST SIGNATURE OF PARTY MAKING REQUEST Received on: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . by __________________________________________________ 9 10

DATE AND TIME [ ] CLERK/DEPUTY CLERK [ ] MAGISTRATE [ ] INTAKE OFFICER

TO THE CLERK: PLACE IN A SEALED ENVELOPE

FORM DC-618 (MASTER) 7/05

Form DC-618 REQUEST FOR CONFIDENTIALITY - CIVIL Form DC-618

Data Elements

1. Court case number. 2. Court jurisdiction, city or county. 3. Check which court is appropriate. 4. Name of case. 5. Check the appropriate box to indicate the proceeding in which the party is involved. 6. Name, address, date of birth, social security number, home telephone number,

employer's name and address, work telephone number and driver's license number of person requesting confidentiality.

7. Date of request. 8. Signature of person making request. To be completed by court personnel: 9. Date received by clerk/magistrate/intake officer. 10. Name of clerk/magistrate/intake officer.

DISTRICT COURT FORMS JULY 2005

Form DC-619 EXEMPLIFICATION OF RECORD Page: 1


a. Original – to court in responding state. b. First copy – to party requesting exemplification if not requested directly by a court.

c. Second copy – to Virginia court (file copy).

2. Prepared by clerk, signed by clerk (not deputy clerk) and judge. 3. Attachments – Any court record requested.



DISTRICT COURT MANUAL FORMS VOLUME

EXEMPLIFICATION OF RECORD Case No. ..................................................................................... 1 Commonwealth of Virginia [ ] General District Court ................................................................................................................................................ [ ] Juvenile and Domestic Relations District Court

2 In Re ..............................................................................................................................................................................................................................................

DECEMBER 2007

........................................................................................................................ v. .....................................................................................................................

3 FULL NAME OF PLAINTIFF/PETITIONER (LAST, FIRST, MIDDLE) FULL NAME OF DEFENDANT/RESPONDENT (LAST, FIRST, MIDDLE) ........................................................................................................................ .....................................................................................................................

FULL NAME OF PLAINTIFF/PETITIONER (LAST, FIRST, MIDDLE) FULL NAME OF DEFENDANT/RESPONDENT (LAST, FIRST, MIDDLE)

DISTRICT COURT CLERK’S ATTESTATION

I, ................................................................................................................................................................................., the Clerk of this Court, in

the .......................................................................................................................................... Judicial District of the Commonwealth of Virginia, attest on this date that the attached papers are true and complete copies of the following documents in the records of the above-styled case in this court:

4

5

..........................................................................................................................................................................................................................................................

6 .......................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... ..........................................................................................................................................................................................................................................................

....................................................................... _____________________________________________________________ DATE CLERK

7

8

DISTRICT COURT JUDGE’S CERTIFICATION

I, .................................................................................................................................................................... , the Judge of this Court, in the aforesaid

9 Judicial District, certify that the above-named District Court Clerk is, and was at the time of signing of the certificate, the Clerk of this District Court, that such Clerk is duly qualified, that the attestation is in proper form and that the signature is genuine.

....................................................................... _____________________________________________________________

10 DATE JUDGE

11 To the Responding Court: This exemplification meets the requirements of the following Act of Congress:

The records and judicial proceedings of any court of any such State, Territory or Possession, or copies thereof, shall be proved or admitted in other courts within the United States and its Territories and Possessions by the attestation of the clerk and seal of the court annexed, if a seal exists, together with a certificate of a judge of the court that the said attestation is in proper form.

Such Acts, records and judicial proceedings or copies thereof, so authenticated, shall have the same full faith and credit in every court within the United States and its Territories and Possessions as they have by law or usage in the courts of such State, Territory or Possession from which they are taken.

(62 Stat. 947) 28 U.S.C.A. § 1738 (emphasis added).

District Courts in Virginia do not have Seals. FORM DC-619 MASTER 11/06


Data Elements 1. Virginia court case number. 2. Name of Virginia court in which the original records are lodged. 3. Style of case – same as on petition or order. 4. Name of clerk signing this attestation. 5. Number of the judicial district in which the court is located. 6. Insert description of records. 7. Date of attestation. 8. Signature of clerk. 9. Name of judge signing this exemplification. 10. Date of certification. 11. Signature of judge.


Form DC-620 AFFIDAVIT Form DC-620 (UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT)

DISTRICT COURT MANUAL FORMS VOLUME SEPTEMBER 2008



b. Other copies as dictated by local practice. 2. Prepared by petitioner or other party filing a pleading in all custody cases; acknowledged by

authorized officer. 3. Attachments –

a. Form DC-511, JUVENILE PETITION/SUMMONS

b. Form DC-630, MOTION TO AMEND OR REVIEW ORDER

c. Form DC-635, MOTION FOR SHOW CAUSE SUMMONS d. Any other pleading where issue of legal custody, physical custody or visitation is raised. 4. Preparation details

a. This affidavit shall be completed in all cases in which legal custody, physical custody, or visitation with respect to a child is an issue. This includes a proceeding for divorce, separation, neglect, abuse, dependency, guardianship, paternity, termination of parental rights, and protection from domestic violence in which the issue may appear.

b. The affiant should list the specific city or county (if known), in Data Elements Nos. 2 and 4

(reverse) when the affiant uses the name of a Virginia city as the name of the locality. If unknown, have affiant insert the locality name used for postal purposes.

AFFIDAVIT (Uniform Child Custody Jurisdiction and Enforcement Act) Case No. ....................................................................................... 1

COMMONWEALTH OF VIRGINIA Va. Code § 20-146.20 [ ] Circuit Court ....................................................................................................................................................................... [ ] Juvenile and Domestic Relations District Court

2

In re: .................................................................................................................................................................................................................................................................... 3

FORM DC-620 (FRONT) 05/08

JUVENILE

.............................................................................................................................. v. ............................................................................................................................... 4

I, ................................................................................................................................... the undersigned affiant, state the following information under oath: 5

6 [ ] Certain information has been omitted from this form and submitted under seal because I allege that the health, safety or liberty of a party or child would be jeopardized by disclosure. Another party may request that a hearing be held to determine whether this information should be disclosed.

1. The child presently resides at: .......................................................................................................................................................................................................... 7 ADDRESS

The c DATE hild commenced residing there on ...................................................................................... and has resided there continuously to this date. 8

2. The other places where and persons with whom this child has lived during the last five (5) years : (please complete reverse side). 9

3. I [ ] have [ ] have not participated, either as a party, witness, or in any other capacity in any other litigation (court proceeding) concerning custody of or visitation with this child, in any State or foreign country. If yes, complete below:

a. Name of Court and State or foreign country in which litigation occurred: ............................................................................................................ 10 b. When did the litigation occur: ..................................................................................................................................................................................................

c. What was the outcome of the litigation: ...............................................................................................................................................................................

d. Attach a copy of all pleadings and Orders filed in this litigation.

4. I [ ] do [ ] do not have knowledge or information of any proceeding that could affect this proceeding, including but not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective orders, abuse and neglect, termination of parental rights and adoptions, which is pending in a court of this or any other State or foreign country. If yes, complete below: a. Name of Court and State or foreign country in which proceeding is pending: .....................................................................................................

................................................................................................................................................................................................................................................................

11

b. Attach a copy of all pleadings filed in the litigation.

5. I [ ] do [ ] do not know of any person who is not already named as a party in this proceeding who has physical custody of this child or who claims to have custody or visitation rights with respect to child. If yes:

a. Name and address of person: .................................................................................................................................................................................................... 12b. Does this person have physical custody of the child? [ ] Yes [ ] No c. State why you believe this person claims to have custody/visitation rights to the child: .................................................................................

.....................................................................................................................................................................................................................................................................

6. I understand that I have an obligation to promptly inform this court if I later become aware of any other proceedings, including but not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective orders, abuse and neglect, termination of parental rights and adoptions, either in this or any other State or foreign country that could affect the current proceeding.

________________________________________________ SIGNATURE OF AFFIANT

13Subscribed and sworn to before me on ................................................. DATE

14

Title: ............................................................................................................ ____________________________________________________________ 15 16

SIGNATURE

17

FOR NOTARY PUBLIC’S USE ONLY:

State of ................................................................................................ [ ] City [ ] County of ................................................................................................

Acknowledged, subscribed and sworn to before me this ...................... day of .................................................................................... , 20 ...............

......................................................................................... ________________________________________________________ NOTARY REGISTRATION NUMBER NOTARY PUBLIC (My commission expires: ................................)



Data Elements, front 1. Court case number. 2. Jurisdiction. 3. Juvenile’s name. 4. When affidavit is used in a divorce case

where custody is at issue, style of the divorce proceeding.

5. Name of affiant. 6. Check this box if the health, safety or

liberty or a party or the child would be jeopardized by the disclosure of information on this form. Omit any such information from this form and enter it on district form DC-620A to be sealed.

7. Present address of child whose custody is

at issue. In Juvenile and Domestic Relations District Court, the child’s name will appear in Data Element No. 3.

8. Date child moved to this address.

9. Complete the reverse of this form. See

data elements for the reverse. 10. Check appropriate response. If

appropriate, insert name of court and state or foreign country, dates, outcome and copies of pleadings in the litigation.

11. Check appropriate response. Indicate

name of court and attach pleadings if appropriate.

12. Check appropriate response. Insert name

and address of person claiming custody and other information as appropriate.

13. Affiant’s signature.

14. For judicial officer, insert date of acknowledgment.

15. For judicial officer, insert title of person

taking affidavit. 16. For judicial officer, insert signature of

person taking affidavit. 17. If acknowledgment taken by notary

public, provide notary’s location, date of acknowledgment, expiration date of commission, notary’s registration number and notary’s signature.



Data Elements, reverse 1. Dates showing beginning and end of time child lived at address listed. Use approximate dates if

exact dates unknown. Example “Feb. 1994 - July 1997.” 2. Street address and name of jurisdiction where child resided previously. If address is the same as

stated in data element #6 from the front of the form, insert “same as front.” 3. Name of person with whom the child resided within the last five years, including the person

with whom the child currently lives. 4. List current address where person with whom the child resided named in data element #3 can

be found. If current address is unknown or the affiant does not know beyond reasonable doubt the current address, use last known address.

Form DC-621 NON-DISCLOSURE ADDENDUM Form DC-621

Using This Form

1. Copies – as many as will be needed for a file copy to be placed in sealed envelope and to attach for use in service.

2. Prepared by petitioner or other party filing a pleading in all protective order cases and in

custody and support cases where the petitioner requests non-disclosure.



a. This form should be used in all protective order cases to collect the name(s), address(es), date(s) of birth, race(s), gender and telephone number(s) of the person(s) to be protected. In cases involving custody, this form should be completed only if the person completing district court form DC-620, AFFIDAVIT, has checked the box on that form requesting that certain information not be disclosed. Only that information that is not included on the DC-620, AFFIDAVIT, should be included on this form. In support cases, this form should be used when a person asserts that there is a protective order in force or where there is an allegation that the petitioner is at risk of physical or emotional harm from the other party.

b. A copy of this form can be used by the sheriff’s department to provide service. It

should be stressed that no information contained on the form should be disclosed to the public or the parties.


THIS IS CONFIDENTIAL INFORMATION

NON-DISCLOSURE ADDENDUM Case No. ........................................................................................

1 Commonwealth of Virginia

[ ] PROTECTIVE ORDER IN PROTECTIVE ORDER CASES, THIS INFORMATION SHALL NOT BE RELEASED EXCEPT BY COURT ORDER OR WHEN NECESSARY FOR USE BY LAW ENFORCEMENT.

[ ] UCCJEA AFFIDAVIT IN CASES IN WHICH A UCCJEA AFFIDAVIT IS REQUIRED AND A PERSON REQUESTS THAT INFORMATION BE KEPT CONFIDENTIAL, THIS INFORMATION SHALL NOT BE RELEASED EXCEPT BY ORDER OF THE COURT.

[ ] PETITION FOR SUPPORT [ ] MOTION TO AMEND [ ] MOTION FOR SHOW CAUSE

2

IN SUPPORT CASES WHERE A PERSON REQUESTS THAT INFORMATION BE KEPT CONFIDENTIAL, THE INFORMATION SHOULD NOT BE RELEASED EXCEPT BY ORDER OF THE COURT.

SHERIFF/PROCESS SERVER: THE INFORMATION CONTAINED IN THIS DOCUMENT IS CONFIDENTIAL AND MAY NOT BE DISCLOSED TO THE PARTIES OR TO THE PUBLIC.

In re: ................................................................................................................................................................................................................................................................... CHILD

3

.............................................................................................................................. v. ..............................................................................................................................

4 ...............................................................................................................................................................................................................................................................................

NAME AND ADDRESS OF PERSON WHOSE INFORMATION IS TO BE PROTECTED

5 ...............................................................................................................................................................................................................................................................................

.............................................................................................................................. ..............................................................................................................................

HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER

6

7

PROTECTIVE ORDER CASES ONLY Information for each protected person or each person requested to be protected. NAME (LAST, FIRST, MIDDLE)

D.O.B. RACE SEX

8

FORM DC-621 REVISED 07/09

SUPPORT CASES ONLY Va. Code § 20-60.3 Include this information for the person whose information is to be protected.

DCSE ID No. ........................................................................................... Driver’s License No. and State: .........................................................................

Social Security No. ................................................................................ Date of Birth: .............................................................................................................

11

12

9

10 UCCJEA AFFIDAVIT USE ONLY Va. Code § 20-146.20E

In addition to above, complete only the information that has been omitted from the DC-620, AFFIDAVIT form:

1. The child presently resides at: .................................................................................................................................................................................................. ADDRESS

The child commenced residing there on ........................................................................ and has resided there continuously to this date. DATE

2. The other places where and persons with whom this child has lived during the last five (5) years include: ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................

3. I know of a person who is not already named as a party in this proceeding who has physical custody of this child or who claims to have custody or visitation rights with respect to the child. The name and address of that person is:

................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................

4. Anything else from the affidavit not contained above: ................................................................................................................................................... ................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................

17

16

15

14

13

Form DC-621 NON-DISCLOSURE ADDENDUM Form DC-621


Data Elements 1. Court case number. 2. Check appropriate box to indicate the type of case. 3. Child’s name, if applicable. 4. Style of case, if applicable. 5. Name and address of person whose information is to be protected. 6. Home telephone number of person named in Data Element No. 5. 7. Work telephone number of person named in Data Element No. 5. 8. If the case involves an order of protection, insert information for each protected person or

each person requesting to be protected. 9. If the case is a matter of support, insert DCSE identification number. 10. Insert social security number of the person whose information is to be protected. 11. Insert driver’s license number and the state of the person whose information is to be

protected. 12. Insert date of birth of the person whose information is to be protected. 13. Present address of child whose custody is at issue if omitted from Affidavit. 14. Date child moved to this address if omitted from Affidavit. 15. Insert addresses of places where child lived in last five years if omitted from Affidavit. 16. Insert name and address of person claiming custody and other information as appropriate. 17. Insert any information from the Affidavit that should not be disclosed that is not already

included on this form.

Form DC-622 SEALED DOCUMENTS Form DC-622

DISTRICT COURT MANUAL FORMS VOLUME MAY 2005

Using This Form

1. Copies - none 2. Prepared by clerk. 3. Attachments – insert all sealed documents into the envelope. 4. Preparation details -- This is a sealed envelope which can be used to contain all documents that

include information that may not be disclosed.

FORM DC-622 REVISED 5/05

SEALED DOCUMENTS Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PROTECTIVE ORDER, UCCJEA and SUPPORT CASES Commonwealth of Virginia

SEALED

Va. Code §§ 16.1-253.1, 16.1-253.4, 16.1-279.1, 19.2-152.8, 19.2-152.9, 19.2-152.10, 20-60.3, 20-146.20 E

[ ] General District Court . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Juvenile and Domestic Relations District Court In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHILD

[ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INSTRUCTIONS TO CLERK:

This envelope contains confidential documents and shall be opened only by authorized court personnel or by order of the Court.

Records contained herein are sealed. Information contained in sealed documents shall not be disclosed except by order of the Court. ENTER AS APPROPRIATE DOCUMENT DESCRIPTION DATE

SEALED INITIALS OF CLERK/DEPUTY

CLERK DC-621 NON-DISCLOSURE ADDENDUM

DC-511 PETITION

DC-618 REQUEST FOR CONFIDENTIALITY—CIVIL

DC-630 MOTION TO AMEND

DC-635 MOTION FOR SHOW CAUSE

DC-346 NOTICE OF NEW TRIAL DATE

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Form DC-622 SEALED DOCUMENTS Form DC-622

DISTRICT COURT MANUAL FORMS VOLUME MAY 2005

Data Elements

1. Court case number. 2. Jurisdiction. Check the applicable box to indicate the court type 3. Child’s name if it is a custody case. 4. Style of case if it is a support case. 5. Check to indicate which documents are contained in the envelope. 6. Place form number, if applicable, and title of other documents contained in the envelope. 7. Include date that documents were sealed. 8. Initials of clerk or deputy clerk who placed the document in the envelope.

Form DC-623 MOTION FOR GENETIC TESTING Page: 1



b. First copy – to party requesting genetic testing.

c. Second copy – to other party in the support or parentage case.

d. Other copies according to local practice. 2. Prepared by party, signed by clerk or notary public. 3. Attachments – none. 4. Preparation details

a. A party to a case involving parentage or child support must make an affidavit alleging or denying paternity when making a motion for genetic testing. Virginia Code § 20-49.3. This form combines the necessary motion and affidavit in one form for the party to execute.

b. Data Elements Nos. 10-14 are to be used if alleging paternity. Data Elements Nos. 15-17

are to be used if denying paternity.




MOTION FOR GENETIC TESTING Case No. ......................................................................................... Commonwealth of Virginia Va. Code § 20-49.3 [ ] Circuit Court ....................................................................................................................................... [ ] Juvenile and Domestic Relations District Court ..................................................................................................................... v/in re ...................................................................................................................... 3 4 PETITIONER RESPONDENT ..................................................................................................................... ...................................................................................................................... 5 6 ALLEGED BIOLOGICAL MOTHER ALLEGED BIOLOGICAL FATHER .............................................................................................................................................................................................................................................................. 7

NAME OF CHILD

I, ............................................................................................................................. being a party to the above-styled case in which 8

parentage of ......................................................................................................................................, is in issue, move the Court for an order that the alleged biological father, the alleged biological mother and the child or children named above, submit to scientifically reliable genetic testing, including blood grouping tests and HLS (human leukocyte antigen) testing, which have been developed and adapted for purposes of establishing or disproving parentage.

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I swear or affirm that: [ ] ...................................................................................................................... is the [ ] biological father [ ] biological mother 10 11

of ................................................................................................................................. and that the following facts establish a reasonable possibility of the requisite sexual contact between the parties: ..............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................. 14 .............................................................................................................................................................................................................................................................. OR [ ] I am not the [ ] biological father [ ] biological mother of .................................................................................................. 17 ..............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................. 18 .............................................................................................................................................................................................................................................................. _____________________________________________________________ 19 SIGNATURE OF PARTY REQUESTING GENETIC TESTING

Subscribed and sworn to before me this the ............................. day of ......................................................................... , ................................. 20 21

My commission expires: ...................................................................... _____________________________________________________________ 23 [ ] CLERK/DEPUTY CLERK [ ] NOTARY PUBLIC FORM DC-623 (MASTER, PAGE ONE OF TWO) 12/01

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1. Court case number of support or parentage case. 2. Jurisdiction and check box for appropriate court. 3. Name of petitioner in child support/parentage case. 4. Name of respondent in child support/parentage case. 5. Name of alleged biological mother. 6. Name of alleged biological father. 7. Name of child whose parentage is the subject of dispute or for whom support is sought. 8. Name of party requesting genetic testing. 9. Name of child whose parentage is the subject of dispute or for whom support is sought. 10. Check this box if alleging paternity. 11. Name of person alleged to be parent. 12. Check appropriate box. 13. Name of child. 14. Insert details supporting allegation. 15. Check this box if denying paternity. 16. Check appropriate box. 17. Name of child. 18. Any additional information. 19. Signature of party requesting genetic testing. 20. Date of affirmation. 21. Month and year of affirmation. 22. Notary commission expiration date if applicable. 23. Signature of person taking affirmation. Check appropriate box.




NOTICE OF HEARING TO: .............................................................................................................................. .............................................................................................................................. TAKE NOTICE THAT A HEARING INVOLVING THIS CASE WILL BE HELD AT ..............................................................................................................................................................................................................................................................

COURT ADDRESS

on ....................................................................................................................... at ................................................................. m. ........................................................................ ______________________________________________________________________ DATE CLERK

SERVICE OF PROCESS ON PERSON TO RECEIVE NOTICE

[ ] Personal service Being unable to make personal service, a copy of delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode or party

named above after giving information of its purport. (List name, age of recipient and relation to party named above.)

..................................................................................................................................................................................................................................................... [ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address

listed above. (Other authorized recipient not found.) [ ] Not found. ........................................................................ ______________________________________________________________________ DATE SERVING OFFICER for __________________________________________________________________ FORM DC-623 (MASTER, PAGE TWO OF TWO) 12/01

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1. Name and address of non-moving party. 2. Court address. 3. Date of hearing. 4. Time of hearing. 5. Date notice issued. 6. Signature of clerk. 7. Serving officer to check this box if personal service obtained. 8. Serving officer to check the appropriate box to designate type of substitute service. 9. If served by leaving copy with a family member age 16 or older, check appropriate box and

insert required information. 10. Serving officer to check this box if unable to serve process. 11. Date of signature. 12. Signature of serving officer. 13. Name of sheriff if served by deputy sheriff.


Form DC-624 PARENTAGE TEST ORDER Form DC-624

Using This Form

1. Copies

a. Original – to court. b. First copy – to alleged mother.

c. Second copy – to alleged father.

d. Third copy – to entity where testing samples are to be obtained.

e. Fourth copy – to entity that will conduct test on samples.

f. Fifth copy – to Division of Child Support Enforcement (DCSE) if DCSE is

involved in case.

2. Prepared by the clerk, signed by judge. 3. Attachments – none.


a. The third and fourth copy of the order should be sent to the entity where the

testing samples are to be obtained, with instructions to forward the fourth copy, together with the samples, to the entity which will conduct the tests on the samples.

b. Data Element Nos. 3, 4, and 5 should conform to the style of the case as shown on

the petition.

c. The order should state what additional identification items, if any, should be brought and who should bring them.

d. The judge may order the Commonwealth to pay if the person who would

otherwise be ordered to pay is indigent, with payment to be made through the Criminal Fund. However, if the Division of Child Support Enforcement (DCSE) is involved in the case, then DCSE can be ordered to initially pay for the test.

e. In setting the next hearind date, the court should take into account the amount of

time needed to transport and test the samples, send the report of the test results to the court, and the 15 day statutory period between the filing of the report in the clerk’s office and the hearing date.


PARENTAGE TEST ORDER Case No. ........................................................................................ 1

Commonwealth of Virginia Va. Code §§ 20-49.3; 20-49.4 [ ] General District Court ................................................................................................................................................ [ ] Juvenile and Domestic Relations District Court 2

..................................................................................................................... v./In re ..................................................................................................................... 3 5 4

..................................................................................................................... ..................................................................................................................... 6 7

ALLEGED BIOLOGICAL MOTHER ALLEGED BIOLOGICAL FATHER .......................................................................................................................................................................................................................................................... child(ren) 8

.............................................................................................................. moved for the entry of this Order. Upon this motion, this Court ORDERS that: 9

1. The alleged biological father, the alleged biological mother, and the child(ren) named above, submit to scientifically reliable

genetic tests, which may include DNA tests which have been developed and adapted for purposes of establishing or disproving parentage.

2. The alleged biological father, the alleged biological mother, and the child(ren) named above, present themselves at this date, time

and place for obtaining testing samples: ...................................................................................................................................................................................................................................................................... 10

LOCATION TELEPHONE NUMBER

...................................................................................................................................................................................................................................................................... 11

DATE AND TIME Each shall produce at that time the following documentation and proof of their identity:

a. A copy of this court order b. Photo identification, such as a driver’s license

c. ............................................................................................................................................................................................................................................................. 12

The parties are to conduct themselves in a proper manner while at the site. The willful failure of any of the parties to present and conduct themselves as ordered may result in the punishment of such parties by a jail sentence or by a fine or by both. Further, the court may order such parties to reimburse the payor for any costs assessed against it for their failure to appear as scheduled or to behave.

3. .......................................................................................................................... shall conduct the tests on the testing samples and shall furnish the

final results of the test to the court. The written report of the test results shall be filed in the clerk’s office of this court at least fifteen (15) days before the next hearing date shown.

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4. .......................................................................................................................... is to initially pay for the cost of the test. If the alleged biological

father is found to be the biological father, then he may be required to reimburse the payor for all costs incurred in obtaining and testing the samples. However, final assessment of such costs shall be made at the end of the case.

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5. .......................................................................................................................... is the next hearing date to which this case is continued. 15

.......................................................................................... _______________________________________________________________________

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17 DATE JUDGE

FORM DC-624 12/01

Form DC-624 PARENTAGE TEST ORDER Form DC-624


Data Elements

1. Insert court case number. If Division of Child Support Enforcement (DCSE) is involved in the case, also add DCSE I.D. number under the court case number.

2. Insert court jurisdiction and check applicable box to indicate type of court.

3. Insert name of petitioner or the Commonwealth. See Using This Form, 4.b.

4. Cross out the part of the case style that is inapplicable. See Using This Form, 4.b.

5. Insert name of the respondent or the subject of the petition. See Using This Form, 4.b.

6. Insert name of alleged biological mother.

7. Insert name of alleged biological father.

8. Insert name of children whose parentage is in dispute.

9. Insert name of party that moved fro the parentage testing.

10. Insert name, street address, and telephone number of place where the people who are to

give testing samples are to report.

11. Insert date and time that people are to give testing samples are to report to the place described in Data Element No. 10.

12. Describe any additional items to be brought to identify the person to be tested. See Using

This Form, 4.c.

13. Insert name of entity that is to conduct the test on the samples. See Using This Form, 4.a.

14. Insert name of entity that shall initially pay for the parentage testing. See Using This Form, 4.d.

15. Insert next hearing date after completion of the testing process. See Using This Form,

4.e.

16. Insert date of entry of order.

17. Insert signature of judge.

Form DC-625 MOTION AND NOTICE AND JUDGMENT Page: 1 FOR ARREARAGES

Using This Form

1. Copies

a. Original - to court. b. First copy - to defendant against whom an order is issued.

2. Petition prepared by petitioner. Notice prepared and signed by clerk. Case Disposition prepared by clerk and signed by judge.

3. Attachments - none. 4. Preparation details

Notice on page two indicates to whom service of process is directed.


Form DC-625 MOTION AND NOTICE AND JUDGMENT FOR ARREARAGES Page: 2

MOTION AND NOTICE AND JUDGMENT FOR ARREARAGES Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Commonwealth of Virginia Va. Code §16.1-278.18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juvenile & Domestic Relations District Court 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

STREET ADDRESS OF COURT 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEFENDANT

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PETITIONER ADDRESS/LOCATION

4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS/LOCATION ADDRESS/LOCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TELEPHONE NUMBER TELEPHONE NUMBER The undersigned respectfully represents to the Court that the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . did on 6 NAME OF COURT AWARDING SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . enter judgment and order the defendant to pay 7 DATE

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . payable to AMOUNT OF PAYMENT AND TERMS OF PAYMENT

8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for the support of NAME OF PAYEE

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

NAME(S) OF DEPENDENT(S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The undersigned states that the defendant has not paid all of the support money ordered by the Court, leaving a

balance due of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , which amount is equal to or greater than . . . . . . . . . . . . . . . . . . months BALANCE DUE NO OF MONTHS

1211 of support payments owed as of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 DATE

Wherefore, the undersigned moves the Court to enter judgment against the defendant on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for the balance due shown above plus any other further delinquent payments as of the date of judgment.

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __________________________________________ DATE PETITIONER

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASE DISPOSITION JUDGMENT that Petitioner(s) recover against Defendant the sum of

$ with interest; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . until paid, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTEREST RATE AND DATE FROM WHICH INTEREST IS DUE

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$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . costs, and $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . attorney’s fees. 18 19 COSTS ATTY FEE 20

21 JUDGMENT FOR DEFENDANT NON-SUIT DISMISSED 22

Defendant(s) present? yes no

23 _________________________________________ 24 25 DATE ENTERED JUDGE FORM DC-625 (MASTER, PAGE ONE OF TWO) 7/05


Data Elements, page one 1. Case number. If form is clipped to file at top of form, put case number at bottom of page; otherwise

put file number at top of page. 2. Court name. 3. Street address of court. 4. Name, address and telephone number of petitioner. 5. Name, address and telephone number of defendant. Additional line is provided for other location

information. 6. Name of court entering judgment for support. 7. Date of entry of judgment by court in Data Element No. 6. 8. Amount and terms of court-awarded payments. 9. Name of person to whom payment was ordered to be made. 10. Name of dependants supported by support payments. 11. Amount of support order arrears. 12. Number of months payments past due. 13. Date as of which support arrearage amount (Data Element No. 11) was correct. 14. Date of signing of petition. 15. Signature of petitioner. 16. Amount of judgment principal. 17. Interest rate in percent and ate from which interest was calculated. 18. Amount of costs awarded by court, if any. 19. Amount of attorney’s fees awarded by court, if any. 20. Check box if judgment entered on this petition for defendant. 21. Check this box if the case is non-suited by plaintiff. 22. Check this box if the case is dismissed. 23. Check the applicable box. 24. Date of entry of order. 25. Signature of judge.

DISTRICT COURT MANUAL FORMS MANUAL DECEMBER 2007

Form DC-625 MOTION AND NOTICE AND JUDGMENT FOR ARREARAGES Page: 4

Case No. ........................................................................................ 1

NOTICE

TO THE DEFENDANT: You are hereby notified that the party who filed this motion will move this Juvenile and Domestic Relations District Court on ..................................................................................... m. to enter judgment against you in the amount of money alleged to be unpaid. 2 DATE AND TIME

................................................................... ___________________________________________ DATE CLERK

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SERVICE OF PROCESS ON DEFENDANT

Personal service

Being unable to make personal service, a copy was delivered in the following manner:

Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purpose. (List name, ages of recipient and relation to party named above.)

Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above.

(Other authorized recipient not found.)

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Delivered to ................................................................................................................................................................................................ the residence. business address of record. 8

Not found 9

.. DATE SERVING OFFICER

........................................................................................ __________________________________________

10 11 for ________________________________________ 12 FORM DC-625 (MASTER, PAGE TWO OF TWO) 6/06




1. Court case number. 2. Date and time of hearing. 3. Date of issuance. 4. Signature of clerk. 5. Serving officer to check this box if personal service obtained. 6. Serving officer to check the appropriate box to designate type of substitute service. 7. If served by leaving a copy with a family member age 16 or older, check appropriate box and

insert required information. 8. Serving officer to check appropriate box(es) and insert to whom process served and check

appropriate box to indicate if it was delivered to residence or business address. 9. Serving officer to check this box if unable to serve process. 10. Date of signature. 11. Signature of serving officer. 12. Name of sheriff if served by deputy sheriff.

DISTRICT COURT MANUAL FORMS MANUAL DECEMBER 2007

Form DC-626 EMERGENCY PROTECTIVE ORDER – Form DC-626 FAMILY ABUSE


Using This Form

1. Copies

a. Original – to judge or magistrate for verification purposes if oral order reduced to writing by law enforcement officer, and then to juvenile and domestic relations district court. If verification not necessary, then directly to the juvenile and domestic relations district court.

b. First copy – to respondent.

c. Second copy – to allegedly abused person.

d. Third copy – the law enforcement officer files this copy with the written report required

by Virginia Code § 19.2-81.3 C. (See subparagraph E of § 16.1-253.4.)

2. Prepared by the magistrate or judge if the allegedly abused person or law enforcement officer requests the order in person. If a law enforcement officer requests the form electronically, the officer prepares the form and the magistrate or judge will verify the order later.

3. Attachments

a. If the allegedly abused person or law enforcement officer requests the order in person at

the same time as presenting evidence in a probable cause hearing in a warrantless arrest situation, the magistrate will attach the documents relating to the criminal offense to this form.


a. If a law enforcement officer requests this order by electronic means, the officer will

complete Data Element Nos. 1 through 23. If the allegedly abused person or law enforcement officer petitions in person before the judge or magistrate, the allegedly abused person or law enforcement officer completes Data Element Nos. 6 through 11.

b. After serving the order, the officer completes the service of process portion, including the

description of the respondent. If the judicial officer issued an oral order, the law enforcement officer must return it to the judge or magistrate who authorized it. Once the officer delivers the order to the judicial officer who authorized it, the judicial officer will review the order for accuracy and will sign the verification section at Data Element Nos. 24 and 25. The certified order must be filed with the clerk of the juvenile and domestic relations district court within five (5) days of issuance of the order.

c. The address and telephone number of the allegedly abused person should not be entered

in the service box on the reverse side of this form. This information is to be kept confidential. District court form DC-621, NONDISCLOSURE ADDENDUM, should be used to collect this information.

d. The officer who executes the order completes the reverse side of this form.


RACE SEX BORN HT. WGT. EYES HAIR

MO. DAY YR. FT. IN.

SSN

DRIVER’S LICENSE NO. STATE EXP.

EMERGENCY PROTECTIVE ORDER — FAMILY ABUSE Court Case No. ...................................................................... Commonwealth of Virginia Va. Code § 16.1-253.4

................................................................................................................................................................................. Juvenile and Domestic Relations District Court

ALLEGEDLY ABUSED PERSON DATE OF BIRTH OF ALLEGEDLY ABUSED PERSON

LAST FIRST MIDDLE

V.

RESPONDENT RESPONDENT IDENTIFIERS (IF KNOWN)

LAST FIRST MIDDLE

................................................................................................................................. RESPONDENT’S ADDRESS/LOCATION .................................................................................................................................

REQUEST FOR EMERGENCY PROTECTIVE ORDER To the individual requesting the order: Please provide information on allegedly abused person and other requested protected persons on form DC-621, NON-DISCLOSURE ADDENDUM. I, the undersigned, assert under oath the following: ................................................................................................................................................................................ .....................................................................................................................................................................................................................................................................................

Therefore, I respectfully request the [ ] issuance [ ] extension of an emergency protective order. In the case of a request for extension, I certify that the person in need of protection is physically or mentally incapable of filing a petition pursuant to Virginia Code § 16.1-253.1 or 16.1-279.1.

......................................................................................................... _________________________________________________________ ....................................... NAME AND AGENCY/RELATIONSHIP TO VICTIM [ ] ALLEGEDLY ABUSED PERSON/PARENT/PERSON IN LOCO PARENTIS DATE (If law enforcement officer, include badge and code no.) [ ] LAW ENFORCEMENT OFFICER

Subscribed and sworn to before me this day [ ] in person [ ] by electronic communication (If oath taken by electronic communication, print or type name of judge or magistrate taking oath.) .................................................... _____________________________________________________ DATE [ ] JUDGE [ ] MAGISTRATE

EMERGENCY PROTECTIVE ORDER Based on the above assertion and other evidence, I find that (if checked below): [ ] A warrant for a violation of § 18.2-57.2 has been issued and there is probable danger of further acts of family abuse

against ......................................................................................................................... by the Respondent; OR FAMILY OR HOUSEHOLD MEMBER

[ ] Reasonable grounds exist to believe that Respondent has committed family abuse and there is probable danger of a further such offense against .............................................................................................................................................................. by the Respondent. FAMILY OR HOUSEHOLD MEMBER

It is ORDERED that the request is hereby [ ] denied [ ] granted and ORDERED that the Respondent shall observe the following conditions: [ ] The Respondent shall not commit acts of family abuse or criminal offenses that result in injury to person or property. [ ] The Respondent shall have no contact of any kind with ............................................................................................................................................................... ............................................................................................................................................................................................................................................................................

[ ] except as follows: ............................................................................................................................................................................................................................... [ ] The allegedly abused person is granted possession of the companion animal described as ............................................................................................. NAME/TYPE

[ ] ................................................................................................................................... , the family or household member, is granted possession of the premises occupied by the parties, located at ................................................................................................................................................................................... ,

to the exclusion of the Respondent; however, no such grant of possession shall affect title to any real or personal property. [ ] Supplemental Sheet to Protective Order, Form DC-653, attached and incorporated by reference. Number of supplemental pages .........................

__________________________________________________________________ [ ] JUDGE [ ] MAGISTRATE

VERIFICATION: I have verified this order. .................................................... ______________________________________________________ DATE [ ] JUDGE [ ] MAGISTRATE

This Order is issued on ..................................................................... DATE

THIS ORDER EXPIRES ON ........................................ at 11:59 p.m. DATE

[ ] CAUTION: Weapon Involved

RESPONDENT: SEE WARNINGS ON REVERSE (Print or type name of judge or magistrate if oral order is reduced to writing by the law enforcement officer.)

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Data Elements, front

1. For clerk’s use only. Insert court case

number. 2. Insert the name of the court.

3. Insert the name of the allegedly abused

person.

4. Insert date of birth of the allegedly abused person.

5. Insert the name of the respondent/

alleged abuser.

6. Address of the respondent.

7. Enter identifying information for respondent, if known.

8. Check this box if a weapon has been

involved in any of the previous altercations between the parties.

9. The person requesting the order inserts

the facts that the person asserts provide the basis for the order.

10. Check appropriate box if issuance or

extension is requested by a law enforcement officer.

11. Name and agency/relationship to victim

of person requesting the order. If law enforcement officer, include badge and code number.

12. Signature of person requesting order.

Check the appropriate box.

13. Insert date of the request for the order.

14. Check whether the request for the order was made in person or by electronic means.

15. Insert the date that the person providing

the information swore to facts.

16. Signature of judge or magistrate. If judge or magistrate takes the oath by electronic means, the law enforcement officer prints the name of the judicial officer instead.

17. Check appropriate box for basis of

issuance of the order, and insert name of family or household member.

18. Check whether the request is granted or

denied.

19. Check appropriate box(es) for conditions imposed as part of the order, including whether the judicial officer orders that possession of the premises occupied by the parties be given to the allegedly abused person to the exclusion of the respondent, and whether the judicial officer orders restrictions on whom the respondent may contact.

20. Check if supplemental sheet attached

and insert the total number of supplemental pages.

21. Insert the date on which the judicial

officer authorizes the order.

22. Insert date on which the order expires.

23. Signature of judicial officer who authorizes the order. Check appropriate title box. If oral order is issued and reduced to writing, the law enforcement officer prints the name of the judicial officer here.

24. Insert the date on which the judicial

officer verifies the order. Complete only if the judicial officer has issued an oral order.

25. Signature of judge or magistrate. Check

appropriate box. Complete only if the judicial officer has issued the order by electronic means.

FORM DC-626 (REVERSE, PAGES ONE AND FOUR) 10/11

RETURNS: Each person was served according to law, as indicated below, unless not found. RESPONDENT NAME ..................................................................................................................................... .................................................................................................................................................... ADDRESS .............................................................................................................................. ....................................................................................................................................................

ALLEGEDLY ABUSED PERSON: (See form DC-621, NON-DISCLOSURE ADDENDUM) NAME .....................................................................................................................................

[ ] PERSONAL SERVICE TELEPHONE NUMBER: ................................................................


[ ] NOT FOUND

[ ] NOT FOUND

__________________________________________________________

SERVING OFFICER

for ___________________________________________ ....................................................................................................................................................

DATE AND TIME

______________________________________________

SERVING OFFICER

for ___________________________________________ .....................................................................................................................................................

DATE AND TIME

Respondent’s Description (for VCIN entry):

RACE .................................. SEX .......................................................................

DOB: .......................................................................................................................................

HGT .................................... WGT .....................................................................................

EYES .................................. HAIR ....................................................................................

SSN ..........................................................................................................................................

Relationship to Petitioner/Plaintiff .............................................................................

Distinguishing features .....................................................................................................

[ ] Copy delivered to ..................................................................................................................................................... .....................................................................................................................................................

..................................................................................................................................................... By .............................................................................................................................................

TITLE .....................................................................................................................................................

SIGNATURE

..................................................................... DATE

WARNINGS TO RESPONDENT:

Pursuant to Code of Virginia § 18.2-308.1:4, Respondent shall not purchase or transport any firearm while this order is in effect. If Respondent has a concealed handgun permit, Respondent must immediately surrender that permit to the court issuing this order. If Respondent violates the conditions of this order, Respondent may be sentenced to jail and/or ordered to pay a fine. This order will be entered into the Virginia Criminal Information Network. The Respondent may at any time file a motion with the court requesting a hearing to dissolve or modify this order; however, this order remains in full force and effect unless and until dissolved or modified by the court. DEFINITIONS:

“Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury. “Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person.

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Data Elements, reverse,

Pages one and four

1. Respondent’s name. 2. Respondent’s address.

3. Respondent’s telephone number.

4. Check this box if respondent receives personal service.

5. Check this box if respondent not found.


7. Name of sheriff if served by deputy sheriff.

8. Date and time order served on respondent or of return.

9. Respondent’s description for entry into VCIN.

10. Name of allegedly abused person.

11. Check this box if allegedly abuse person receives personal service.

12. Check this box if service attempted on the allegedly abused person but person is not

found.



15. Date and time of service or return.

16. Check this box if, instead of service of the order, the order is delivered to the allegedly abused person or a family or household member. Insert name of person to whom copy of the order is given.

17. Title of individual giving copy of order to allegedly abused person.

18. Signature of individual giving copy of order to allegedly abused person.


FORM DC-626 (REVERSE, PAGES TWO AND THREE) 10/11

WARNINGS TO RESPONDENT:

Pursuant to Code of Virginia § 18.2-308.1:4, Respondent shall not purchase or transport any firearm while this order is in effect. If Respondent has a concealed handgun permit, Respondent must immediately surrender that permit to the court issuing this order. If Respondent violates the conditions of this order, Respondent may be sentenced to jail and/or ordered to pay a fine. This order will be entered into the Virginia Criminal Information Network. The Respondent may at any time file a motion with the court requesting a hearing to dissolve or modify this order; however, this order remains in full force and effect unless and until dissolved or modified by the court. DEFINITIONS:

“Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury. “Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person.

Form DC-627 PRELIMINARY PROTECTIVE ORDER – Form DC-627 FAMILY ABUSE


Using This Form

1. Copies


c. Second copy – to petitioner/plaintiff.

2. Prepared by clerk, signed by judge. 3. Attachments – none.


a. This order must be served on the respondent. District court form DC-510, SUMMONS, may be prepared for serving the petition on all of the parties, even when the order is served at the same time as the petition, or the summons on district court form DC-611, PETITION FOR PROTECTIVE ORDER – FAMILY ABUSE, may be used. See Virginia Code §§ 16.1-263 and 16.1-264.

b. Data Element Nos. 15 through 20 on page one and Data Element Nos. 2 through 8

on page two – see Virginia Code §§ 16.1-253.1 and 16.1-253.3 regarding relief that may ordered.

c. The address and telephone number of the allegedly abused person should not be

entered in the service box on the reverse of this form. This information is to be kept confidential. District court form DC-621, NONDISCLOSURE ADDENDUM, should be used to collect this information.

FORM DC-627 (MASTER, PAGE ONE OF ______) 10/11


MO. DAY YR. FT. IN.

SSN


PRELIMINARY PROTECTIVE ORDER – FAMILY ABUSE Case No. ................................................................................... Commonwealth of Virginia VA. CODE § 16.1-253.1 Hearing Date and Time: ..................................................... [ ] Circuit Court (on appeal only) ..................................................................................................................................................... [ ] Juvenile and Domestic Relations District Court

[ ] Extension of Preliminary Protective Order

PETITIONER PETITIONER’S DATE OF BIRTH

LAST FIRST MIDDLE

And on behalf of minor family or household members: Other protected family or household members: (list each name and date of birth) (list each name and date of birth) ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................

V.


LAST FIRST MIDDLE

Petitioner’s relationship to Respondent: ................................................................................................................................ ................................................................................................................................ RESPONDENT’S ADDRESS

................................................................................................................................ Distinguishing features: ........................................................................... ................................................................................................................................

THE COURT FINDS that it has jurisdiction over the parties and subject matter, and that 1. The Petitioner is a family or household member of the Respondent;

2. The Petitioner is, or has been, within a reasonable period of time, subjected to family abuse; and

3. In order to protect the health and safety of the Petitioner or any family or household member of the Petitioner, a preliminary protective order is warranted.

[ ] Ex Parte Proceeding Only: The petition has been supported by an affidavit or sworn testimony before the judge or intake officer, and either the Petitioner is in immediate and present danger of family abuse or there is sufficient evidence to establish probable cause that family abuse has recently occurred so as to justify an ex parte proceeding.

THE COURT ORDERS that: [ ] The Respondent shall not commit acts of family abuse or criminal offenses that result in injury to person or property.

[ ] The Respondent shall have no contact of any kind with the Petitioner

[ ] except as follows: ................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................

[ ] The Respondent shall have no contact of any kind with the family or household members of the Petitioner named above


............................................................................................................................................................................................................................................................

[ ] Additional terms of this order are set forth on page two.


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3. Court name. Check appropriate box.

4. Check if an extension of preliminary protective order.

5. Petitioner’s full legal name.

6. Petitioner’s date of birth.

7. List name and date of birth of each minor family or household member.

8. List name and date of birth of other protected family or household members.

9. Respondent’s full legal name.

10. Insert petitioner’s relationship to respondent.

11. Insert address where respondent is located.


13. Check this box if a weapon has been involved in previous altercations between the

parties.

14. Check this box if requirements for an ex parte hearing have been met.

15. Check if ordered. 16. Check if ordered.

17. If applicable, check this box and specify exceptions to condition that respondent have no

contact with the petitioner.

18. Check if ordered. 19. If applicable, check this box and specify exceptions to condition that respondent have no

contact with the family or household members of the petitioner named in the order. 20. Check box if additional terms of this order are set forth on page two.

FORM DC-627 (MASTER, PAGE TWO OF ______) 07/14

Case No. .......................................................................... It is further ORDERED as follows: [ ] The Petitioner is granted possession of the residence occupied by the parties to the exclusion of the Respondent.

The residence is located at .................................................................................................................................................................................................. The Respondent shall immediately leave and stay away from the residence; however, no such grant of possession shall affect title to any real or personal property.

[ ] The Respondent shall not terminate [ ] Respondent shall restore necessary utility service(s) to the premises

indicated above, specifically, ............................................................................................................................................................................................ UTILITY SERVICE(S)

[ ] The Petitioner is granted temporary exclusive possession or use of a motor vehicle jointly owned by the parties or

owned by the Petitioner alone, described as follows: ..........................................................................................................................................

..................................................................................................................................................... Such grant shall not affect title to the vehicle. [ ] The Respondent shall provide suitable alternative housing for the Petitioner [ ] and family or household members

as follows: ................................................................................................................................................................................................................................... [ ] The Respondent shall pay deposit(s) to connect or restore necessary utility service(s) in the alternative housing,

specifically, ................................................................................................................................................................................................................................. UTILITY SERVICE(S)

[ ] The Petitioner is granted possession of the companion animal described as .......................................................................................... NAME/TYPE

[ ] It is further ordered that ....................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................ [ ] Supplemental Sheet to Protective Order, Form DC-653, attached and incorporated by reference. Number of supplemental pages ...........................

It is further ORDERED that a full hearing on the petition for a protective order be held at this Court on .................................... at ........................................................................ and that notice of this hearing be given to the Respondent.

[ ] It is ORDERED that the Preliminary Protective Order is extended [ ] as the Respondent failed to appear at the protective order hearing set for ............................................................ because

the Respondent was not personally served or, if personally served, was incarcerated and not transported to the hearing.

[ ] upon motion of the Respondent and for good cause shown. ...................................................................... __________________________________________________________________ DATE JUDGE

WARNINGS TO RESPONDENT: Only the court can change this order. Pursuant to Code of Virginia § 18.2-308.1:4, Respondent shall not purchase or transport any firearm while this order is in effect. If Respondent has a concealed handgun permit, Respondent must immediately surrender that permit to the court issuing this order. If Respondent violates the conditions of this order, Respondent may be sentenced to jail and/or ordered to pay a fine. This order will be entered into the Virginia Criminal Information Network. Either party may at any time file a motion with the court requesting a hearing to dissolve or modify this order; however, this order remains in full force and effect unless and until dissolved or modified by the court. DEFINITIONS: “Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury.

“Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person.

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1. Court case number. 2. If petitioner is given exclusive possession of the residence occupied by the parties, check

this box. Insert the address of the residence.

3. Check appropriate box regarding utility services, if ordered.

4. Check if ordered and insert description of vehicle.

5. Check if applicable and insert names of persons for whom housing must be provided and other orders relating to housing.

6. Check if payment of deposit(s) for utility service(s) for alternative housing is ordered and

indicate specific utility service(s).

7. Check box, if applicable, and insert description (including name and type, if known) of companion animal.

8. Insert any additional terms.

9. Check if a SUPPLEMENTAL SHEET TO PROTECTIVE ORDER, form DC-653, is attached and insert number of supplemental pages.

10. Insert date of full hearing.

11. Insert time of full hearing.

12. Check if the PRELIMINARY PROTECTIVE ORDER is extended.

13. Check to indicate reason for extension of PRELIMINARY PROTECTIVE ORDER. If

applicable, insert date respondent did not appear for a full hearing.

14. Date order signed by judge.


FORM DC-627 (MASTER, PAGE THREE OF ______) 04/13

Case No. ................................................................................... RETURNS: Each person was served according to law, as indicated below, unless not found.

RESPONDENT:

NAME .................................................................................................................................... .................................................................................................................................................... ADDRESS ............................................................................................................................ ....................................................................................................................................................


NAME ................................................................................................................................... ....................................................................................................................................................

[ ] PERSONAL SERVICE TELEPHONE NUMBER .................................................................


[ ] NOT FOUND [ ] NOT FOUND

__________________________________________________________

SERVING OFFICER

for _____________________________________________________ .................................................................................................................................................

DATE AND TIME

________________________________________________________

SERVING OFFICER

for _____________________________________________________ ..................................................................................................................................................

DATE AND TIME

RESPONDENT’S DESCRIPTION (for VCIN entry):

RACE ................................ SEX .......................................................................

DOB: .......................................................................................................................................

HGT .................................... WGT .....................................................................................

EYES ................................. HAIR ....................................................................................

SSN .........................................................................................................................................

Relationship to Petitioner/Plaintiff ............................................................................

Distinguishing features ...................................................................................................

....................................................................................................................................................


by ............................................................................................................................................. TITLE

.....................................................................................................................................................

SIGNATURE .....................................................................................................................................................

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Data Elements, page three


2. Name of respondent (to be completed by serving officer). 3. Address of respondent.

4. Telephone number of respondent.

5. Serving officer to check this box if personal service obtained.

6. Serving officer to check this box if unable to serve process.



9. Date and time of signature.

10. Description of respondent (for VCIN entry).

11. Name of petitioner. Do not provide the petitioner’s address or telephone number (see

Using This Form, 4.c.).






17. Check this box if, instead of service of the order, the order is delivered to the petitioner or family or household member. Insert name of person to whom copy of the order is given.

18. Title of individual giving copy of order to petitioner.

19. Signature of individual giving copy of the order to petitioner.

Form DC-628 ORDER FOR SUPPORT (CIVIL) Page: 1


Using This Form

1. Copies

a. Original – to court. b. First copy – to respondent. c. Second copy – to petitioner. d. Third copy – to Virginia Department of Social Services, Division of Child Support

Enforcement (DCSE) if payment through DCSE is ordered. e. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge. 3. Attachments

a. Performance Bond, if required - to original copy only. b. Form DC-639, CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO ORDER FOR

SUPPORT, if needed. See Using This Form, 4.d. c. Form DC-644, ORDER DETERMINING PARENTAGE, if needed.


a. This order is used when support is ordered pursuant to any statute and incorporates all

provisions required by Virginia Code § 20-60.3.

b. This order can be used in both in-state and UIFSA civil cases.

c. When payment is ordered through the Division of Child Support Enforcement, Data Element No. 8 on Page 2 must be checked unless otherwise ordered for good cause shown.

d. If child support guidelines are not followed, Form DC-639, CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO ORDER FOR SUPPORT should be attached to show why child support guidelines were not followed in this case in addition to showing the amount that results from the guidelines calculations.

e. Petitioner or respondent may request that Data Elements 7 and 8 or 9 and 10 on page one not be printed, except for the name of the party, if a protective order has been issued or the court finds that the petitioner or respondent is at risk of physical or emotional harm.

f. NOTE: In cases involving the adjudication of paternity, use Form DC-644, ORDER DETERMINING PARENTAGE. Do not make the finding on this form.

Form DC-628 ORDER OF SUPPORT (CIVIL) Page: 2


ORDER OF SUPPORT (CIVIL) This Court’s Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonwealth of Virginia DCSE ID No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] TEMPORARY ORDER [ ] FINAL ORDER

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Juvenile and Domestic Relations District Court [ ] Circuit Court

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STREET ADDRESS OF COURT

Petitioner: v. Respondent: [ ] Identifying information not provided for good cause shown [ ] Identifying information not provided for good cause shown Residential Address: Residential Address: Residential Telephone No.: Residential Telephone No.: Mailing Address if Different: Mailing Address if Different:

Social Security No. (last 4 digits only): Social Security No. (last 4 digits only): Driver’s Lic. No. & State: Driver’s Lic. No. & State: Date of Birth: Date of Birth: Employer: Employer: Address: Address: Telephone No.: Telephone No.: [ ] This case is DISMISSED without prejudice because the Respondent could not be located for service of process. [ ] Upon hearing the evidence, the Court finds for the Respondent and ORDERS that the case be DISMISSED. PRESENT: [ ] Petitioner [ ] Attorney/ Guardian Ad Litem for Petitioner [ ] DCSE Representative [ ] Attorney for DCSE [ ] Respondent [ ] Attorney/ Guardian Ad Litem for Respondent [ ] Guardian Ad Litem for child(ren) [ ] Other [ ] Upon hearing the evidence, the Court finds that [ ] this (these) dependents [ ] a parent of the Respondent in necessitous circumstances: NAME SOC. SEC. # (last 4 digits only) SEX DATE OF BIRTH RELATIONSHIP TO RESPONDENT is (are) entitled to support from the Respondent, and that the Respondent is chargeable with support as alleged in the petition. Therefore, the Court ORDERS the Respondent to pay:

[ ] $ . . . . . . . . . . . . . . . . . . . . . . per month CURRENT CHILD SUPPORT effective . . . . . . . . . . . . . . . . . . . . for all children listed above; OR [ ] $ . . . . . . . . . . . . . . . . . . . . . . per month CURRENT CHILD SUPPORT effective . . . . . . . . . . . . . . . . . . . . divided among the above-listed children as follows:

$ . . . . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . .

[ ] $. . . . . . . . . . . . . . . . . . . . . . per month CURRENT SPOUSAL SUPPORT effective . . . . . . . . . . . . . . . . . . . . [ ] $. . . . . . . . . . . . . . . . . . . . . . per month COMBINED CHILD-SPOUSAL (UNITARY) SUPPORT effective . . . . . . . . . . . . . . . . . . . . [ ] $. . . . . . . . . . . . . . . . . . . . . . per month SUPPORT FOR A PARENT effective . . . . . . . . . . . . . . . . . . . .

[ ] $. . . . . . . . . . . . . . . . . . . . . . per month PAYMENT TOWARDS ARREARAGES OF $ . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL $ . . . . . . . . . . . . . . . . . . per month payable, first payment due on the 1st day of ……………………., and each subsequent payment

is due on the 1st day of each month thereafter. Payments may be made in intervals of ………………….., per ……………….., beginning

on ……………………… .PAYMENT AMOUNT INTERVAL DATE

All support paid shall be credited to current support first and the remainder shall be credited to arrearages. Child support shall terminate on a child’s eighteenth birthday; however, support shall continue for any child who is over the age of eighteen and (i) a full-time high school student, (ii) not self-supporting and (iii) living in the home of the parent receiving child support, until the child reaches the age of nineteen or graduates from high school, whichever occurs first; and if any arrearages for child support, including interest or fees, exist at the time the youngest child emancipates, payments shall continue in the total amount due until all arrearages are paid. If the above current child support is not divided per child, the ordered amount cannot be changed except by a court. [ ] Continuing support for , a child whom the court has determined (i) is severely and permanently mentally

Name of Child

or physically disabled, (ii) is unable to live independently and support himself and (iii) resides in the home of the parent seeking support. FORM DC-628 (PAGE ONE OF THREE) 07/10

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Data Elements, page one 1. Court case number of the court entering the

order. Juvenile and Domestic Relations District courts - use adult number assignment and indexing procedures.

2. DCSE (Division of Child Support

Enforcement) case identification number, if applicable.

3. Check box to indicate if the order is

temporary or final. 4. Court name and type. 5. Street address of court. 6. Check box if information regarding one of

the parties is not included due to domestic violence.

7. Name, residential address, mailing address,

if different, residential telephone number, last four digits of social security number, driver's license number and birth date of petitioner.

8. Name, address and telephone number of

petitioner's employer. 9. Name, residential address, mailing address,

if different, residential telephone number, last four digits of social security number, driver's license number and birth date of respondent.


respondent's employer. 11. Check if applicable in this case. 12. Check if applicable in this case. 13. Check the appropriate boxes designating

those present at the hearing.

14. Check if applicable in this case and insert information on all dependents (including petitioner if applicable) for whom support is ordered.

15. If order provides for current (ongoing)

support, check this box, insert the total periodic amount of current support and effective date.

16. If separate child support is ordered, insert

the total child support award and effective date, the amount allocated to each child, and the name of the child to whom the amount is allocated.

17. If separate spousal support is ordered, check

this box, insert the amount and effective date.

18. If a combined child/spousal support award is

made, check the box, insert the amount and effective date.

19. If support for a parent is ordered, check this

box, insert the amount and effective date. 20. Check this box if arrearages are owed and

enter monthly payment toward arrearage. 21. Total amount of arrearages owed. 22. Total monthly amount due. 23. Insert month in which first payment is due. 24. Amount of each interval payment. 25. Time (week, month, etc.) for which each

interval payment is applicable. 26. Date when the indicated amount of support

becomes effective. 27. Check if applicable and insert name of child.



ORDER OF SUPPORT (CIVIL) Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ARREARAGES: [ ] No arrearages exist as of . . . . . . . . . . . . . . . . . .

[ ] $ . . . . . . . . . . . . . . . . . child support arrearage owed by Respondent. .

[ ] $ . . . . . . . . . . . . . . . . . spousal support arrearage owed by Respondent.

[ ] $ . . . . . . . . . . . . . . . . . unitary (child/spousal) support arrearage owed by Respondent.

[ ] $ . . . . . . . . . . . . . . . . . total SUPPORT arrears owed by Respondent [ ] with interest included [ ] without interest included

[ ] arrears include an assessment from the effective date of this order to the first payment due date.

[ ] This total includes TANF debt or other public funds paid prior to the effective date of this order of $ . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . months.

These arrearages are calculated as of the date of this Order including support owed for the current month. This amount does not include payments made after ____/____/____, and respondent shall be credited for any payments made thereafter. Interest shall continue to accrue on unpaid arrearages at the judgment rate unless the petitioner, in a writing submitted to the court, waives the collection of interest. PAYMENT: Payment shall be made payable to: [ ] Petitioner at the address shown in the beginning of the Order.

The parties shall give the court at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the court informed of the name, address, and telephone number of his/her current employer.

[ ] Treasurer of Virginia and sent to Virginia Department of Social Services, Division of Child Support Enforcement, P.O. Box 570, Richmond, Virginia 23218-0570 unless otherwise instructed by that agency or this Court and shall contain the following:

1. Check or money order made payable to the Treasurer of Virginia. 2. Print on the check or money order:

Your name and social security number Petitioner’s name as shown on the first page of this order The DCSE ID No. shown on the first page of this order. If no such number is shown, use this Court’s name and case number as

shown on the front page of this order until that number is sent to you; then start using the DCSE ID No. The parties shall give to the Virginia Department of Social Services and the court, at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the Virginia Department of Social Services and the court informed of the name, address and telephone number of his/her current employer.

[ ] The parties shall also give each other at least 30 days written notice, in advance of any change of residential and, if different, mailing address and of any change in telephone number within 30 days after the change.

WARNING: Failure to pay in accordance with this order is a violation of this order and may be punished by a jail sentence or a fine or both. In addition, you may not receive credit for payments made contrary to the payment instructions provided in this order. Whenever income withholding is authorized, it is your responsibility to make the payment to DCSE until the income withholding becomes effective. You are responsible for keeping records of payments you make. HEALTH CARE PROVISIONS: [ ] Respondent [ ] Petitioner shall provide health care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents [ ] Respondent [ ] Petitioner shall provide dental care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents [ ] Respondent [ ] Petitioner presently has health care coverage and is ordered to maintain it or comparable coverage. Health Insurance Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name of Policy Holder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In the event of any change in health insurance, the responsible party is required to notify the opposing party of the change. The

responsible party shall inform the Virginia Department of Social Services, if support payments are ordered to be paid through the Virginia Department of Social Services, or the opposing party, if support payments are ordered to be paid directly to the opposing party, of any changes in the availability of the health care coverage for the minor child or children.

[ ] The Court finds that “health care coverage” as defined by the statute is not available at “reasonable cost” as defined by statute, and therefore, the Court does not order either the Respondent or the Petitioner to provide health care coverage.

[ ] Any reasonable and necessary unreimbursed medical and dental expenses for each child covered by this order shall be paid in the following manner: . . . . . . . . . . . . . . % Respondent . . . . . . . . . . . . . % Petitioner. FORM DC-628 (PAGE TWO OF THREE) 07/14

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Data Elements, page two 1. Court case number. 2. Check this box if no arrearages exist and enter the appropriate date. 3. If order provides for arrearages, check the appropriate box(es) and show the arrearages due for each

box checked. 4. Insert total amount of support arrears owed and check appropriate box indicating inclusion or non-

inclusion of interest. 5. Check this box if arrears listed in Data Element No. 3 includes assessment from the effective date of

the order to the first payment due date. 6. Check the box if applicable and include amount and, if monthly payment amount is provided, number

of months. 7. If an arrearage calculation report is generated for the court and serves as the basis for the court’s

arrearage determination, and the report’s arrearage calculation date (i.e., the “as of” date or the last date included in the arrearage amount calculation) is earlier than the date of the court’s order, insert the report’s calculation date.

8. Check the person or institution to whom payment is to be sent. 9. Check if ordered. See Using This Form, 4.g. 10. If health care coverage is ordered, check which party is to provide coverage, and also check for whom

the coverage will be provided. 11. If dental care coverage is ordered, check which party is to provide coverage, and also check for whom

the coverage is provided. 12. Check box identifying person who presently has coverage if that person is ordered to continue

coverage. Provide present health insurance policy information in the spaces provided. 13. If health care coverage is not provided for the reasons stated in this provision, check this box. 14. If the parties are to pay all or a portion of uninsured health care expenses, check the box and insert the

applicable percentages for respondent’s obligation and for petitioner’s obligation.



ORDER OF SUPPORT (CIVIL) Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Respondent [ ] Petitioner is ordered to execute the appropriate tax forms or waivers to grant the other party the right to take the income tax dependency exemption for tax years . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHILD OR CHILDREN

for federal and state income tax purposes. [ ] The Court finds that a license, certificate, registration or other authorization to engage in a profession, business, trade, occupation, or

recreational activity issued by the Commonwealth of Virginia is held by TYPE OF LICENSE AGENCY GRANTING LICENSE LICENSE NUMBER

Respondent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Petitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upon a delinquency of a support payment for a period of 90 days or more, or in an amount of $5,000 or more, a petition may be filed for suspension of any license, certificate, registration or other authorization to engage in a profession, trade, business, occupation, or recreational activity issued by the Commonwealth. Virginia Code § 20-60.3.

[ ] Withholding from income is ordered payable through the Virginia Department of Social Services by [ ] court income deduction order or [ ] administrative order for income withholding. [ ] Immediate withholding from income is not ordered, pursuant to a written agreement between the parties or for good cause shown. It is further ORDERED that: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] This Order was determined based on [ ] sole [ ] shared [ ] split custody guidelines. [ ] A child support award of $ . . . . . . . . . . . . . . . . . . . . . . . . . by application of the guidelines provided in Virginia Code § 20-108.2 would be

unjust or inappropriate in this case as determined by the relevant evidence pertaining to the factors set forth in the attached supplement which is incorporated herein by reference, the ability of each party to provide child support, and the best interest of the child.

[ ] Entered in accordance with the parties’ written stipulation or agreement. [ ] The Respondent is also required to post with the Clerk a recognizance pursuant to § 20-114 of $ . . . . . . . . . . . with/without surety . . . . . . . . . . [ ] The Respondent shall also pay: $ . . . . . . . . . . . . . . . . . . . . . . . . . . reimbursement of costs to the Petitioner due . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . . . attorneys’ fees to the Petitioner’s attorney due . . . . . . . . . . . . . . . . . .

If arrearage amount equals or exceeds 3 months owed, reasonable attorneys’ fees must be ordered pursuant to Virginia Code § 16.1-278.18, and may be ordered pursuant to § 20-78.2.

NOTICE: Support payments may be withheld as they become due from income without further amendment of this order or having to file an application for services with the Virginia Department of Social Services. Such order shall only be entered upon motion after proper notice sent by the clerk or counsel. Support payments may be withheld without further amendment of this order upon application for services with the Virginia Department of Social Services. In determining a support obligation, the support obligation as it becomes due and unpaid creates a judgment by operation of law. Failure to make payments when due means that interest will accrue according to Virginia Code § 6.1-330.54. The Virginia Department of Social Services may initiate a review of the amount of support ordered by any court. If a change in circumstances, as defined in the State Board of Social Services’ regulations, has occurred, the Department shall report its findings and a proposed modified order to the court which entered the order. Notice shall be served on both parties. Either party may request a hearing on the proposed modified order by filing a request with such court within 30 days of receipt of notice by the requesting party. Unless a hearing is requested with the time limits, no hearing shall be required and the modified order shall be effective 30 days after the notice is received and shall amend any prior court order. Virginia Code § 20-60.3.

In cases enforced by the Virginia Department of Social Services, the Department of Motor Vehicles may suspend or refuse to renew the driver’s license of any person upon receipt of notice from the Virginia Department of Social Services that the person is delinquent in the payment of child support by 90 days or in an amount of $5,000 or more, or the person has failed to comply with a subpoena, summons, or warrant relating to paternity or child support proceedings. If the order being reviewed by the Department deviates from the guidelines, based on one or more factors set out in Virginia Code § 20-108.1, a hearing shall be scheduled with the court which entered the order. THIS ORDER SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL AMENDED OR ANNULLED BY THIS COURT OR A COURT OF COMPETENT JURISDICTION TO WHICH AN APPEAL MAY BE TAKEN.

. . . . . . . . . . . . . . . . . . . . . . . . . . . __________________________________________________________ DATE JUDGE

SEEN AND AGREED AS TO NO PROVISION FOR INCOME WITHHOLDING.

PETITIONER: RESPONDENT: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FORM DC-628 (PAGE THREE OF THREE) 07/09

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Data Elements, page three 1. Court case number. 2. Check appropriate box if applicable, and enter applicable tax years and name of child(ren) to which it

is applicable. 3. Indicate whether respondent or petitioner holds an occupational, business, professional or recreational

license, and insert the type of license, the agency granting the license and the license number. 4. Check box indicating immediate withholding is ordered, if applicable, and then check box indicating

method of withholding. 5. Check box if income withholding is not ordered. 6. Insert information if order is to contain additional terms. 7. Indicate the type of guidelines used in calculating support. 8. If child support was awarded and the statutory child support guidelines calculations were not

followed, check the box, insert the amount that results from the guidelines calculations, and complete form DC-639, CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO ORDER FOR SUPPORT. See Using This Form, 4.h.

9. Check box if applicable. 10. Check the box if a performance bond is to be posted. 11. Amount of bond, if bond is to be posted. 12. Type of security pledged to secure bond. 13. If costs are awarded, check the box and insert total amount of each type of cost awarded and due date. 14. Date of entry of order. 15. Signature of judge. 16. Signature of Petitioner if this document is used to memorialize agreement as to no provision for

income withholding. 17. Signature of Respondent if this document is used to memorialize agreement as to no provision for

income withholding.

Form DC-629 ORDER OF SUPPORT (CRIMINAL) Page: 1



a. Original--to court.

b. First copy--to respondent.

c. Second copy--to petitioner.

d. Third copy--to Virginia Department of Social Services, Division of Child Support Enforcement (DCSE) if payment through DCSE is ordered.

e. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge. 3. Attachments

a. Performance Bond, if required--to original copy only.

b. Form DC-639, CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO ORDER FOR SUPPORT, if needed. See Using This Form, 4.c.

c. Form DC-644, ORDER DETERMINING PARENTAGE, if needed. 4. Preparation details

a. This order is used when support is ordered pursuant to the criminal nonsupport statute, Va. Code § 20-61, and incorporates all provisions required by Virginia Code § 20-60.3.

b. When payment is ordered through the Division of Child Support Enforcement, Data element No. 7 on page 2 must be checked unless otherwise ordered for good cause shown.

c. If child support guidelines are not followed, Form DC-639, CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO ORDER FOR SUPPORT, should be attached to show why child support guidelines were not followed in this case in addition to showing the amount that results from the guidelines calculations.

d. Petitioner or respondent may request that Data Elements 7 and 8 or 9 and 10 on page one not be printed, except for the name of the party, if a protective order has been issued or the court finds that the petitioner or respondent is at risk of physical or emotional harm.

e. NOTE: In cases involving the adjudication of paternity, use Form DC-644, ORDER DETERMINING PARENTAGE. Do not make the finding on this form.



ORDER OF SUPPORT (CRIMINAL) This Court’s Case No. .......................................................................... Commonwealth of Virginia DCSE ID No. ........................................................................................... [ ] TEMPORARY ORDER [ ] FINAL ORDER

........................................................................................................................... [ ] Juvenile and Domestic Relations District Court [ ] Circuit Court ......................................................................................................................................................................................................................................................................................

STREET ADDRESS OF COURT

.............................................................................................................................. v. ................................................................................................................................

Petitioner: [ ] Identifying information not provided for good cause shown Accused: [ ] Identifying information not provided for good cause shown

Residential Address ................................................................................................ Residential Address ...............................................................................................

................................................................................................................................. ................................................................................................................................

................................................................................................................................. ................................................................................................................................

Residential Telephone No. ...................................................................................... Residential Telephone No. .....................................................................................

Mailing Address if different .................................................................................... Mailing Address if different ...................................................................................

................................................................................................................................. ................................................................................................................................

Social Security No.(last 4 digits only) ..................................................................... Social Security No. (last 4 digits only) ...................................................................

Driver’s Lic. No. & State ........................................................................................ Driver’s Lic. No. & State .......................................................................................

Date of Birth ........................................................................................................... Date of Birth ..........................................................................................................

Employer ................................................................................................................ Employer ...............................................................................................................

Address ................................................................................................................... Address ..................................................................................................................

Telephone No. .......................................................................................... Telephone No. .........................................................................................

[ ] Upon hearing the evidence, the Court finds that the Accused is not guilty of unlawfully and willfully and without cause, deserting and willfully neglecting or refusing to provide for the support and maintenance of the individuals named in the petition as dependents.

PRESENT: [ ] Petitioner [ ] Attorney/Guardian Ad Litem for Petitioner [ ] DCSE Representative [ ] Attorney for DCSE [ ] Respondent [ ] Attorney/Guardian Ad Litem for Respondent [ ] Guardian Ad Litem for child(ren) [ ] Other ....................................

[ ] Upon hearing the evidence on the verified petition filed by the Petitioner, the Court finds that the accused is guilty in that he/she did unlawfully and willfully without cause, desert or willfully neglect and refuse and fail to provide for the support and maintenance of the below named dependents as required by law:

NAME SOC. SEC # (last 4 digits only) SEX DATE OF BIRTH RELATIONSHIP TO RESPONDENT

......................................................................................................................................................................................................................................................................................

......................................................................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................................................... Therefore, the Court ORDERS the Respondent: [ ] to pay $ ................................................................................. fine plus all costs assessed in the case, all payable to the clerk of this court. [ ] to serve .................................................................................................................... confinement in jail.

[ ] with the accused being required to participate in a work release program to provide support and maintenance for his dependants. [ ] which sentence is suspended until all of the minor children embraced by this Order have reached their age of majority and have a capacity for

earning a living or are otherwise emancipated, upon condition that the accused pay the amount indicated below. [ ] to pay [ ] $ .................................... per month CURRENT CHILD SUPPORT for all children listed above; OR [ ] $ .................................... per month CURRENT CHILD SUPPORT divided among the above-listed children as follows:

$ ............................................. for .................................................. $ ................................................. for ........................................................... $ ............................................. for .................................................. $ ................................................. for ...........................................................

[ ] $ .................................... per month CURRENT SPOUSAL SUPPORT [ ] $ .................................... per month COMBINED CHILD-SPOUSAL (UNITARY) SUPPORT [ ] $ .................................... per month PAYMENT TOWARDS ARREARAGES OF $ ...........................................

TOTAL $ ................................................ per month payable $ ........................................ per ..................................... beginning on ................................................... AMOUNT INTERVAL DATE All support paid shall be credited to current support first and the remainder shall be credited to arrearages. Child support shall terminate on a child’s eighteenth birthday; however, support shall continue for any child who is over the age of eighteen and (i) a full-time high school student, (ii) not self-supporting and (iii) living in the home of the parent receiving child support, until the child reaches the age of nineteen or graduates from high school, whichever occurs first. If the above current child support is not divided per child, the ordered amount cannot be changed except by a court. [ ] Continuing support for ......................................................................... , a child whom the court has determined (i) is severely and permanently mentally NAME OF CHILD or physically disabled, (ii) is unable to live independently and support himself, and (iii) resides in the home of the parent seeking support. FORM DC-629 (MASTER, PAGE ONE OF THREE) 07/10

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1. Court case number of the court entering the

order. J&DR courts - use adult number assignment and indexing procedures.

2. DCSE (Division of Child Support Enforcement) case identification number, if applicable.

3. Check box to indicate if the order is

temporary or final. 4. Court name and type. 5. Street address of court. 6. Check box if information regarding one of

the parties is not included due to domestic violence.

7. Name, residential address, mailing address,

if different, residential telephone number, last four digits of social security number, driver's license number and birth date of petitioner.


petitioner's employer. 9. Name, residential address, mailing address,

if different, residential telephone number, last four digits of social security number, driver's license number and birth date of respondent.


respondent's employer. 11. Check if applicable in this case. 12. Check the appropriate boxes designating

those present at the hearing. 13. Check if applicable in this case and insert

information on all dependents (including petitioner if applicable) for whom support is ordered.

14. Check box and insert amount of fine if fine

imposed.

15. Check box and insert amount of time if confinement in jail is imposed.

16. If data element 15 is checked, check

appropriate box if accused is required to participate in work release or if the sentence is suspended.

17. If ordered to pay support, check this box. 18. If order provides for current (ongoing)

support, check this box and insert the total periodic amount of current support.

19. If separate child support is ordered, insert

the total child support award, the amount allocated to each child, and the name of the child to whom the amount is allocated.

20. If separate spousal support is ordered, check

this box and insert the amount. 21. If a combined child/spousal support award is

made, check the box and insert the amount. 22. Check this box if arrearages are owed and

enter monthly payment toward arrearage. 23. Total amount of arrearages owed. 24. Total monthly amount due. 25. Amount of each payment. 26. Time (week, month, etc.) for which each

payment is applicable. 27. Date on which first payment is due. 28. Check if applicable and insert name of child.



Case No. ................................................................. ARREARAGES: [ ] No arrearages exist as of .................................................................................

[ ] $ .................................................................. support arrearages exist as follows: $ .................................................................. child support arrearage $ .................................................................. spousal support arrearage $ .................................................................. combined child/spousal (unitary) support arrearage $ ................................................ accrued interest as of ............................................ [ ] interest has not been calculated but is owed on the arrearages

These arrearages are calculated as of .......................................................... but nothing contained in this Order shall affect arrearages accruing after this date. Interest shall continue to accrue on the unpaid arrearages at the judgment rate unless the petitioner, in a writing submitted to the court, waives the collection of interest.

PAYMENT: Payment shall be made payable to: [ ] Petitioner at the address shown in the beginning of the Order.

The parties shall give the court at least thirty (30) days written notice, in advance, of any proposed change of address and of any change of telephone number within 30 days after the change. The Respondent is required to keep the court informed of the name, address, and telephone number of his/her current employer.



Your name and social security number Petitioner’s name as shown on the first page of this order The DCSE ID No. shown on the first page of this order. If no such number is shown, use this Court’s name and case

number as shown on the front page of this order until that number is sent to you; then start using the DCSE ID No. The parties shall give to the Virginia Department of Social Services and the Court, at least thirty (30) days written notice, in advance, of any proposed change of address and of any change of telephone number within 30 days after the change. The Respondent is required to keep the Virginia Department of Social Services and the Court informed of the name, address and telephone number of his/her current employer.

[ ] The parties shall also give each other at least thirty (30) days written notice, in advance of any change of address and of any change in telephone number within thirty days after the change.

WARNING: Failure to pay in accordance with this order is a violation of this order and may be punished by a jail sentence or a file or both. In addition, you may not receive credit for payments made contrary to the payment instructions provided in this order. Whenever income withholding is authorized, it is your responsibility to make the payment to DCSE until the income withholding becomes effective. You are responsible for keeping records of payments you make.

HEALTH CARE PROVISIONS: [ ] Respondent [ ] Petitioner shall provide health care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary

for the use of such coverage by the dependents [ ] Respondent [ ] Petitioner shall provide dental care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary

for the use of such coverage by the dependents. [ ] Respondent [ ] Petitioner presently has health care coverage and is ordered to maintain it or comparable coverage. Health Insurance Company ....................................................................................................... Policy name ............................................................................. Name of Policy Holder ............................................................................................................... Policy number ......................................................................... In the event of any change in health insurance, the responsible party is required to notify the opposing party of the change. The


[ ] The Court finds that “health care coverage” as defined by the statute is not available “at reasonable cost” as defined by statute, and therefore, the Court does not order either the Respondent or the Petitioner to provide health care coverage.

[ ] Any reasonable and necessary unreimbursed medical and dental expenses for each child covered by this order shall be paid in the following manner: ........................................... % Respondent .......................................... % Petitioner. FORM DC-629 (MASTER, PAGE TWO OF TWO) 07/14

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Data Elements, page two 1. Court case number. 2. Check this box if no arrearages exist and enter the appropriate date. 3. If order provides for arrearages, check this box and show the total amount of arrearages due. 4. Show how each portion of the arrearages is allocated. 5. Either insert the amount of accrued interest and the appropriate date or check box indicating

that interest has not been calculated. 6. Date to which arrearages are calculated. 7. Check the person or institution to whom payment is to be sent. 8. Check if ordered. See Using This Form, 4.b. 9. If health care coverage is ordered, check which party is to provide coverage, and also check

for whom the coverage will be provided. 10. If dental care coverage is ordered, check which party is to provide coverage, and also check

for whom the coverage is provided. 11. Check box identifying person who presently has coverage if that person is ordered to

continue coverage. Provide present health insurance policy information in the spaces provided.

12. If health care coverage is not provided for the reasons stated in this provision, check this box. 13. If the parties are to pay all or a portion of uninsured health care expenses, check the box and

insert the applicable percentages for respondent’s obligation and for petitioner’s obligation.



Case No. ............................................................... [ ] Respondent [ ] Petitioner is ordered to execute the appropriate tax forms or waivers to grant the other party the right to take the income tax dependency exemption for tax years ........................................... for ....................................................................................................................................... CHILD OR CHILDREN

for federal and state income tax purposes.

[ ] The Court finds that a license, certificate, registration or other authorization to engage in a profession, business, trade, occupation, or recreational activity issued by the Commonwealth of Virginia is held by

TYPE OF LICENSE AGENCY GRANTING LICENSE LICENSE NUMBER

Respondent ...................................................................... .............................................................................. .........................................................................

Petitioner ...................................................................... .............................................................................. .........................................................................

Upon a delinquency of a support payment for a period of 90 days or more, or in an amount of $5,000 or more, a petition may be filed for suspension of any license, certificate, registration or other authorization to engage in a profession, trade, business, occupation or recreational activity issued by the Commonwealth. Virginia Code § 20-60.3.

[ ] Withholding from income is ordered payable through the Virginia Department of Social Services by [ ] court income deduction order or [ ] administrative order for income withholding.

[ ] Immediate withholding from income is not ordered, pursuant to a written agreement between the parties or for good cause shown. It is further ORDERED that:

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This Order was determined based on [ ] sole [ ] shared [ ] split custody guidelines.

A child support award of $ ............................................................................................................................................................. by application of the guidelines provided in Virginia Code § 20-108.2 would be unjust or inappropriate in this case as determined by the relevant evidence pertaining to the factors set forth in the attached supplement which is incorporated herein by reference, the ability of each party to provide child support, and the best interest of the child.

[ ] Entered into accordance with the parties’ written stipulation or agreement. [ ] The Respondent is also required to post with the clerk a performance bond of $ ...................................................................... with/without surety. [ ] The Respondent shall also pay: $ ............................................................... costs to the clerk of this Court, $ ....................................................................

to the Virginia Department of Social Services as reimbursement for attorney’s fees and other costs, $ .................................................................... attorney’s fees to the Petitioner’s attorney.

NOTICE: Support payments may be withheld as they become due from income without further amendment of this order or having to file an application for services with the Virginia Department of Social Services. Such Order shall only be entered upon motion after proper notice sent by the clerk or counsel. Support payments may be withheld without further amendment of this order upon application for services with the Virginia Department of Social Services. In determining a support obligation, the support obligation as it becomes due and unpaid creates a judgment by operation of law. Failure to make payments when due means that interest will accrue according to Virginia Code § 6.1-330.54. The Virginia Department of Social Services may initiate a review of the amount of support ordered by any court. If a change in circumstances, as defined in the State Board of Social Services’ regulations, has occurred, the Department shall report its findings and a proposed modified order to the court which entered the order. Notice shall be served on both parties. Either party may request a hearing on the proposed modified order by filing a request with such court within thirty days of receipt of notice by the requesting party. Unless a hearing is requested with the time limits, no hearing shall be required and the modified order shall be effective thirty days after the notice is received and shall amend any prior court order. Virginia Code § 20-60.3.

In cases enforced by the Virginia Department of Social Services, the Department of Motor Vehicles may suspend or refuse to renew the driver’s license of any person upon receipt of notice from the Virginia Department of Social Services that the person is delinquent in the payment of child support by 90 days or in an amount of $5,000 or more, or the person has failed to comply with a subpoena, summons, or warrant relating to paternity or child support proceedings. If the order being reviewed by the Department deviates from the guidelines, based on one or more factors set out in Virginia Code § 20-108.1, a hearing shall be scheduled with the court which entered the order.

THIS ORDER SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL AMENDED OR ANNULLED BY THIS COURT OF COMPETENT JURISDICTION TO WHICH AN APPEAL MAY BE TAKEN.

...................................................................... _____________________________________________________________ DATE JUDGE SEEN AND AGREED AS TO NO PROVISION FOR INCOME WITHHOLDING.

PETITIONER: RESPONDENT: ........................................................................................................................... ........................................................................................................................... FORM DC-629 (MASTER, PAGE THREE OF THREE) 07/09

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Data Elements, page three 1. Court case number. 2. Check appropriate box if applicable, and enter applicable tax years and name of child(ren) to

which it is applicable. 3. Indicate whether respondent or petitioner holds an occupational, business, professional or

recreational license, and insert the type of license, the agency granting the license and license the number.

4. Check box indicating immediate withholding is ordered if applicable, and then check box

indicating method for withholding. 5. Check box if income withholding is not ordered. 6. Insert information if order is to contain additional terms. 7. Indicate the type of guidelines used in calculating support. 8. If child support was awarded and the statutory child support guidelines calculations were not

followed, check the box, insert the amount that results from the guidelines calculations, and complete form DC-639, CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO ORDER FOR SUPPORT. See Using This Form, 4.c.

9. Check box if applicable. 10. Check the box if a performance bond is to be posted. 11. Amount of bond, if bond is to be posted. 12. If costs are awarded, check the box and indicate total amount of each type of cost awarded. 13. Date of entry of order. 14. Signature of judge. 15. Signature of Petitioner if this document is used to memorialize agreement as to no provision

for income withholding. 16. Signature of Respondent if this document is used to memorialize agreement as to no

provision for income withholding.

Form DC-630 MOTION TO AMEND OR REVIEW ORDER Form DC-630


Using This Form

1. Copies (Contact the court or court services unit (Intake Office) to determine if you should bring copies with you or if copies will be made upon filing.)


b. First copy – to person being served.

c. Additional copies as determined by local practice.

2. Motion portion prepared by person requesting that order be amended. Notice portion prepared by clerk. Order portion prepared by clerk and signed by judge.

3. Attachments

a. Copy of underlying court order to be changed, amended and/or modified.

b. Cases in which legal custody, physical custody or visitation with respect to a child is an issue, district court form DC-620, AFFIDAVIT.


a. This form may be used when requesting the court to change, amend or modify an existing court order.

b. Data Element Nos. 5 or 6 and 7 should show original style of case. Signature line enables person making the Motion to indicate whether he was the original petitioner or respondent.

FORM DC-630 FRONT 05/05

MOTION TO AMEND OR REVIEW ORDER Case No. ............................................................................. Commonwealth of Virginia [ ] General District Court ................................................................................................................................... [ ] Juvenile and Domestic Relations District Court ......................................................................................................................................................................................................................................................

COURT ADDRESS

This motion is filed in connection with Case No. .................................................................................... [ ] In re ..................................................................................................................................................................................................................................

NAME OF CHILD

[ ] ........................................................................................................ v. ......................................................................................................... PETITIONER RESPONDENT ................................................................................................................. ......................................................................................................... ADDRESS/LOCATION ADDRESS/LOCATION ................................................................................................................. ......................................................................................................... ................................................................................................................. ......................................................................................................... TELEPHONE NUMBER TELEPHONE NUMBER The undersigned respectfully represents to the Court that an order dated ............................................................... was entered DATE

by the [ ] above-named Court [ ] ............................................................................................................................................................. Court ......................................................................................................................................................................................................................................................

REQUIREMENTS OF ORDER ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... [ ] The undersigned moves that the attached order be changed, amended, and/or modified as follows: ......................................................................................................................................................................................................................................................

CHANGES, AMENDMENTS AND/OR MODIFICATIONS TO ORDER ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... ......................................................................................................................................................................................... for the following reason(s): ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................... [ ] The undersigned moves for a hearing on the modifications of the above order proposed by the Department of

Social Services and that the Court take whatever other action it deems necessary. .............................................................................. ____________________________________________________ DATE [ ] PETITIONER [ ] RESPONDENT

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1. Court case number. If form is clipped to file at top of page, put case number at bottom of page. Otherwise, put case number at top of page.

2. Court name.

3. Court address.

4. Reference the case number of the connected case.

5. Check and indicate the name of the child if this is an “in re” case.

6. Name, street address and telephone number of original petitioner in case.

7. Name, street address and telephone number of original respondent in case.

8. Date of entry of earlier order which this Motion seeks to amend.

9. Check and, when necessary, complete the name of the court which entered the earlier order.

10. Provisions of earlier order which person making Motion seeks to change.

11. Provisions which the person making Motion would like to have added to order or have order changed to include.

12. Reasons for the desired changes in the order.

13. Check if a hearing is requested on the changes to the specified order proposed by the Department of Social Services.

14. Date of signing of Motion.

15. Signature of person making Motion.

FORM DC-630 REVERSE 10/13

Case No. .............................................................................

NOTICE ......................................................................................................................................................................................................................................................

(PARTY TO BE SERVED)

You are hereby notified that on ............................................................................................................... , a hearing will be held by this DATE AND TIME

Court to consider a motion to change, amend, and/or modify the terms of an order as described in the Request on the reverse side. ..................................................................... ____________________________________________________________ DATE CLERK

SERVICE OF PROCESS ON PARTY TO BE SERVED [ ] Personal service Being unable to make personal service, a copy was delivered in the following manner:

[ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport (List name, ages, of the recipient and relation to party named above.)

............................................................................................................................................................................................................................

[ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.)

[ ] Not found .............................................................................. _________________________________________________________________ DATE SERVING OFFICER for _____________________________________________________________

CASES TO ENFORCE CHILD SUPPORT ONLY:

[ ] Delivered to ........................................................................................................................... the

[ ] residential [ ] business address of record.

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Data Elements, reverse 1. Court case number. If form is clipped to file at top of page, put case number at bottom of

page. Otherwise, put case number at top of page. 2. Name of person to be served. 3. Date and time of hearing on Motion. 4. Date of issuance. 5. Signature of clerk. 6. Serving officer to check this box if personal service obtained. 7. Serving officer to check the appropriate box to designate type of substitute service. 8. If served by leaving a copy with a family member age 16 or older, check appropriate box and

insert required information. 9. Serving officer to check this box if unable to serve process. 10. Child support enforcement cases only: check applicable boxes and insert address where

delivered. 11. Date of signature. 12. Signature of serving officer. 13. Name of sheriff if served by deputy sheriff.

Form DC-631 MEDIATION SUPPORT AGREEMENT Form DC-631


Using This Form

1. Copies


b. First copy – to respondent.


d. Third copy – to Virginia Department of Social Services, Division of Child Support Enforcement (DCSE) if payment through DCSE is ordered.

e. Additional copies as determined by local practice.

2. Prepared by mediator, and signed by mediator, parties, and attorneys for the parties.

3. Attachments

a. Child Support Guidelines prepared by mediator.

4. Preparation details This form is designed to be used only when the parties reach an agreement in mediation as to child support.

FORM DC-631 (MASTER, PAGE ONE OF THREE) 10/12

MEDIATION SUPPORT AGREEMENT (DATED .......................................... ) This Court’s Case No. .............................................. Commonwealth of Virginia DCSE ID No. ...............................................................

......................................................................................................... [ ] Juvenile and Domestic Relations District Court [ ] Circuit Court

..................................................................................................................................................................................................................................................................................... STREET ADDRESS OF COURT

Petitioner: v. Respondent: [ ] Identifying information not provided for good cause shown [ ] Identifying information not provided for good cause shown Residential Address: Residential Address: Residential Telephone No.: Residential Telephone No.: Mailing Address if Different: Mailing Address if Different:

Social Security No. (last 4 digits only): Social Security No. (last 4 digits only): Driver’s Lic. No. & State: Driver’s Lic. No. & State: Date of Birth: Date of Birth: Employer: Employer: Address: Address: Telephone No.: Telephone No.:

PRESENT: [ ] Petitioner [ ] Attorney/ Guardian Ad Litem for Petitioner [ ] DCSE Representative [ ] Attorney for DCSE [ ] Respondent [ ] Attorney/ Guardian Ad Litem for Respondent [ ] Guardian Ad Litem for child(ren) [ ] Mediator [ ] The parties agree that [ ] this (these) dependents [ ] a parent of the Respondent in necessitous circumstances: NAME SOC. SEC. # (last 4 digits only) SEX DATE OF BIRTH RELATIONSHIP TO RESPONDENT

is (are) entitled to support from the Respondent, and that the Respondent is chargeable with support as alleged in the petition. Therefore, the parties agree that the Respondent to pay:

[ ] $ ......................................... per month CURRENT CHILD SUPPORT effective .......................................... for all children listed above; OR [ ] $ ......................................... per month CURRENT CHILD SUPPORT effective .......................................... divided among the above-listed children as follows:

$ .............................................. for .............................................. $ .............................................. for .............................................. $ .............................................. for .............................................. $ .............................................. for ..............................................

[ ] $ ......................................... per month CURRENT SPOUSAL SUPPORT effective ....................................... [ ] $ ......................................... per month COMBINED CHILD-SPOUSAL (UNITARY) SUPPORT effective ..................................... [ ] $. ......................................... per month SUPPORT FOR A PARENT effective ......................................... [ ] $ ......................................... per month PAYMENT TOWARDS ARREARAGES OF $ .........................................

TOTAL $ .................................. per month payable, first payment due on the 1st day of ........................................ , and each subsequent payment

is due on the 1st day of each month thereafter. Payments may be made in intervals of .................................... , per ............................. , beginning PAYMENT AMOUNT INTERVAL

on ............................................ DATE

All support paid shall be credited to current support first and the remainder shall be credited to arrearages. Child support shall terminate on a child’s eighteenth birthday; however, support shall continue for any child who is over the age of eighteen and (i) a full-time high school student, (ii) not self-supporting and (iii) living in the home of the parent receiving child support, until the child reaches the age of nineteen or graduates from high school, whichever occurs first; and if any arrearages for child support, including interest or fees, exist at the time the youngest child emancipates, payments shall continue in the total amount due until all arrearages are paid. If the above current child support is not divided per child, the ordered amount cannot be changed except by a court. [ ] Continuing support for , a child whom the court has determined (i) is severely and permanently mentally

Name of Child

or physically disabled, (ii) is unable to live independently and support himself and (iii) resides in the home of the parent seeking support.

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1. Date of Mediation Support Agreement.

2. Court case number of the court entering the order. Juvenile and Domestic Relations District courts - use adult number assignment and indexing procedures.

3. DCSE (Division of Child Support Enforcement) case identification number, if applicable.

4. Court case type.

5. Street address of court.

6. Check box if information regarding one of the parties is not included due to domestic violence.

7. Name, residential address, mailing address, if different, residential telephone number, last four digits of social security number, driver's license number and birth date of petitioner.

8. Name, address and telephone number of petitioner's employer.

9. Name, residential address, mailing address, if different, residential telephone number, last four digits of social security number, driver's license number and birth date of respondent.

10. Name, address and telephone number of respondent's employer.

11. Check the appropriate boxes indicating those persons present at the mediation.

12. Check if applicable in this case and insert information on all dependents (including petitioner, if applicable) for whom support is agreed upon.

13. If agreement provides for current (ongoing) support, check this box, insert the total periodic amount of current support and effective date.

14. If separate child support is agreed upon, insert the total child support award and effective date, the amount allocated to each child, and the name of the child to whom the amount is allocated.

15. If separate spousal support is agreed upon, check this box, insert the amount and effective date.

16. If a combined child/spousal support award is agreed upon, check the box, insert the amount and effective date.

17. If support for a parent is agreed upon, check this box, insert the amount and effective date.

18. Check this box if arrearages are owed and enter monthly payment toward arrearage.

19. Total amount of arrearages owed.

20. Total monthly amount due.

21. Insert month in which first payment is due.

22. Amount of each interval payment.

23. Time (week, month, etc.) for which each interval payment is applicable.

24. Date when the indicated amount of support becomes effective.

25. Check if applicable and insert name of child.

FORM DC-631 (MASTER, PAGE TWO OF THREE) 07/14

MEDIATION SUPPORT AGREEMENT Case No. ..................................................................

ARREARAGES: [ ] No arrearages exist as of ....................................

[ ] $ ................................ child support arrearage owed by Respondent.

[ ] $ ................................ spousal support arrearage owed by Respondent.

[ ] $ ................................ unitary (child/spousal) support arrearage owed by Respondent.

[ ] $ ................................ total SUPPORT arrears owed by Respondent [ ] with interest included [ ] without interest included

[ ] arrears include an assessment from the effective date of this order to the first payment due date.

[ ] This total includes TANF debt or other public funds paid prior to the effective date of this order of $ ...................................

for ....................... months. These arrearages are calculated as of the date of this Agreement including support owed for the current month. This amount does not include payments made after ____/____/____, and respondent shall be credited for any payments made thereafter. Interest shall continue to accrue on unpaid arrearages at the judgment rate unless the petitioner, in a writing submitted to the court, waives the collection of interest.

PAYMENT: Payment shall be made payable to:

[ ] Petitioner at the address shown in the beginning of the Agreement. The parties shall give the court at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the court informed of the name, address, and telephone number of his/her current employer.



Your name and social security number Petitioner’s name as shown on the first page of this agreement The DCSE ID No. shown on the first page of this agreement. If no such number is shown, use this Court’s name and case

number as shown on the front page of this agreement until that number is sent to you; then start using the DCSE ID No. The parties shall give to the Virginia Department of Social Services and the court, at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the Virginia Department of Social Services and the court informed of the name, address and telephone number of his/her current employer.

[ ] The parties shall also give each other at least 30 days written notice, in advance of any change of residential and, if different, mailing address and of any change in telephone number within 30 days after the change.

HEALTH CARE PROVISIONS: [ ] Respondent [ ] Petitioner shall provide health care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents [ ] Respondent [ ] Petitioner shall provide dental care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents [ ] Respondent [ ] Petitioner presently has health care coverage and shall maintain it or comparable coverage.

Health Insurance Company ..................................................................................................... Policy name ...................................................................................

Name of Policy Holder ............................................................................................................. Policy number ............................................................................... In the event of any change in health insurance, the responsible party is required to notify the opposing party of the change. The


[ ] The parties agree that “health care coverage” as defined by the statute is not available at “reasonable cost” as defined by statute, and therefore, the parties agree that neither the Respondent nor the Petitioner will be required to provide health care coverage. [ ] Any reasonable and necessary unreimbursed medical and dental expenses for each child covered by this agreement shall be paid

in the following manner: .............................................. % Respondent ............................................... % Petitioner.

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2. Check this box if no arrearages exist and enter the appropriate date.

3. If agreement provides for arrearages, check the appropriate box(es) and show the arrearages due for each box checked.

4. Insert total amount of support arrears owed and check appropriate box indicating inclusion or

non-inclusion of interest.

5. Check this box if arrears listed in Data Element No. 3 includes assessment from the effective date to the first payment due date.

6. Check the box if applicable and include amount and, if monthly payment amount is provided,

number of months.

7. If an arrearage calculation report is generated for the court and serves as the basis for the agreement, and the report’s arrearage calculation date (i.e., the “as of” date or the last date included in the arrearage amount calculation) is earlier than the date of the agreement, insert the report’s calculation date.

8. Check the person or institution to whom payment is to be sent.

9. Check if applicable. See Using This Form, 4.g.

10. If health care coverage is agreed upon, check which party is to provide coverage, and also check

for whom the coverage will be provided.

11. If dental care coverage is agreed upon, check which party is to provide coverage, and also check for whom the coverage is provided.

12. Check box identifying person who presently has coverage if that person has agreed to continue

coverage. Provide present health insurance policy information in the spaces provided.

13. If health care coverage is not provided for the reasons stated in this provision, check this box.

14. If the parties are to pay all or a portion of uninsured health care expenses, check the box and insert the applicable percentages for respondent’s obligation and for petitioner’s obligation

FORM DC-631 (MASTER, PAGE THREE OF THREE) 10/13

MEDIATION SUPPORT AGREEMENT Case No. ..................................................................

[ ] Respondent [ ] Petitioner agree to execute the appropriate tax forms or waivers to grant the other party the right to take the income tax dependency exemption for tax years . ....................................... for ........................................................................................................................... CHILD OR CHILDREN

for federal and state income tax purposes. [ ] A license, certificate, registration or other authorization to engage in a profession, business, trade, occupation, or recreational activity

issued by the Commonwealth of Virginia is held by TYPE OF LICENSE AGENCY GRANTING LICENSE LICENSE NUMBER

Respondent ......................................................... ............................................................................ ..........................................................................

Petitioner ......................................................... ............................................................................ ..........................................................................

Upon a delinquency of a support payment for a period of 90 days or more, or in an amount of $5,000 or more, a petition may be filed for suspension of any license, certificate, registration or other authorization to engage in a profession, trade, business, occupation, or recreational activity issued by the Commonwealth. Virginia Code § 20-60.3.

[ ] Withholding from income will be ordered payable through the Virginia Department of Social Services by [ ] court income deduction order or [ ] administrative order for income withholding.

[ ] Immediate withholding from income will not be ordered, pursuant to this written agreement between the parties. The parties further agree that: .....................................................................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................................................................

[ ] This agreement was determined based on [ ] sole [ ] shared [ ] split custody guidelines, a copy of which is incorporated in this agreement.

[ ] The parties agree to a child support amount that is different than the amount based on the child support guidelines, a copy of which is incorporated in this agreement, for the following reasons: ............................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

[ ] The Respondent is also required to post with the Clerk a recognizance pursuant to § 20-114 of $ ...................... with/without surety ................

[ ] The Respondent shall also pay: $ ......................................... reimbursement of costs to the Petitioner due ......................................

$ ......................................... attorneys’ fees to the Petitioner’s attorney due ........................................... If arrearage amount equals or exceeds 3 months owed, reasonable attorneys’ fees must be ordered pursuant to Virginia Code § 16.1-278.18, and may be ordered pursuant to § 20-78.2.

Mediation conducted by: ................................................................................. ______________________________________________ ............................. NAME OF MEDIATOR SIGNATURE OF MEDIATOR DATE UNDERSTANDING AND DISCLOSURE: The parties agree that the terms and conditions set forth in this agreement are the result of full and substantial disclosure of all relevant property and financial information. The parties further understand that they have the opportunity to have this Mediation Agreement reviewed by independent legal counsel prior to signing it or have chosen to waive the opportunity to do so. Notice: Any party who has legal counsel of record may not waive the opportunity to have this agreement reviewed by legal counsel. The parties understand and request that this agreement be incorporated into the order for support which will contain any additional legal requirements for support orders under Virginia law. .................................. ________________________________________ .................................. _________________________________________ DATE PETITIONER DATE RESPONDENT SEEN: (if represented by counsel) .................................. ________________________________________ .................................. _________________________________________ DATE ATTORNEY FOR PETITIONER DATE ATTORNEY FOR RESPONDENT .................................. ________________________________________ DATE ATTORNEY FOR DCSE

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2. Check appropriate box if applicable, and enter applicable tax years and name of child(ren) to which it is applicable.

3. Indicate whether respondent or petitioner holds an occupational, business, professional or recreational license, and insert the type of license, the agency granting the license and the license number.

4. Check box indicating immediate withholding, if applicable, and then check box indicating method of withholding.

5. Check box if income withholding is not agreed upon.

6. Insert information if parties agree upon additional terms.

7. Indicate the type of guidelines used in calculating support.

8. Indicate the reasons why the parties agreed to a child support amount different than the amount based on the guidelines.

9. Check the box if a performance bond is to be posted.

10. Amount of bond, if bond is to be posted.

11. Type of security pledged to secure bond.

12. If costs are agreed upon, check the box and insert total amount of each type of cost awarded and due date.

13. Insert name of mediator.

14. Signature of mediator conducting the mediation.

15. Date signed by mediator.

16. Signature of petitioner and date signed.

17. Signature of respondent and date signed.

18. Signature of attorneys involved in the case and dates signed.

Form DC-632 ORDER OF SUPPORT (CIVIL) FOR Form DC-632 MEDIATION SUPPORT AGREEMENT


Using This Form

1. Copies


b. Copies to petitioner and respondent.

2. Prepared by judge.

3. Attachments

a. Form DC-631, MEDIATION SUPPORT AGREEMENT.


This order is issued if the parties reach an agreement in mediation on the issue of child support, and such agreement is reflected on form DC-631, MEDIATION SUPPORT AGREEMENT.


ORDER OF SUPPORT (CIVIL) FOR This Court’s Case No. ..................................................................... MEDIATION SUPPORT AGREEMENT Commonwealth of Virginia VA. CODE §§ 8.01-576.11; 20-124.4 DCSE ID No. ..................................................................................... [ ] Circuit Court ........................................................................................................................... [ ] Juvenile and Domestic Relations District Court CITY/COUNTY ........................................................................................................................... v. ........................................................................................................................... PETITONER RESPONDENT This court, having previously determined that the matter was appropriate for referral to a dispute resolution orientation session pursuant to Virginia Code § 20-124.4, now finds that:

1. The parties participated in mediation; 2. The parties entered into a written Mediation Support Agreement dated .......................................................... ; and DATE OF AGREEMENT

3. The parties now request that this court incorporate their written agreement in the order in this case in accordance with Virginia Code § 8.01-576.11.

The court, therefore, orders that the parties’ Mediation Support Agreement dated ..................................................... , which DATE OF AGREEMENT

includes the child support guidelines worksheet and, if applicable, the written reasons for any deviation from the guidelines, is hereby incorporated in this order and both parties are ORDERED to comply fully with the terms of this order.

WARNING: Failure to pay in accordance with this order is a violation of this order and may be punishable by a jail sentence or a fine or both. In addition, you may not receive credit for payments made contrary to the payment instructions provided in this order. Whenever income withholding is authorized, it is your responsibility to make the payment to DCSE until the income withholding becomes effective. You are responsible for keeping records of payments you make.

NOTICE: Support payments may be withheld as they become due from income without further amendment of this order or having to file an application for services with the Virginia Department of Social Services. Such order shall only be entered upon motion after proper notice sent by the clerk or counsel. Support payments may be withheld without further amendment of this order upon application for services with the Virginia Department of Social Services. In determining a support obligation, the support obligation as it becomes due and unpaid creates a judgment by operation of law. Failure to make payments when due means that interest will accrue according to Virginia Code § 6.1-330.54. The Virginia Department of Social Services may initiate a review of the amount of support ordered by any court. If a change in circumstances, as defined in the State Board of Social Services’ regulations, has occurred, the Department shall report its findings and a proposed modified order to the court which entered the order. Notice shall be served on both parties. Either party may request a hearing on the proposed modified order by filing a request with such court within thirty days of receipt of notice by the requesting party. Unless a hearing is requested within the time limits, no hearing shall be required and the modified order shall be effective thirty days after the notice is received and shall amend any prior court order. Virginia Code § 20-60.3. In cases enforced by the Virginia Department of Social Services, the Department of Motor Vehicles may suspend or refuse to renew the driver’s license of any person upon receipt of notice from the Virginia Department of Social Services that the person is delinquent in the payment of child support by 90 days or in an amount of $5,000 or more, or the person has failed to comply with a subpoena, summons, or warrant relating to paternity or child support proceedings. If the order being reviewed by the Department deviates from the guidelines, based on one or more factors set out in Virginia Code § 20-108.1, a hearing shall be scheduled with the court which entered the order.

THIS ORDER SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL AMENDED OR ANNULLED BY THIS COURT OR A COURT OF COMPETENT JURISDICTION TO WHICH AN APPEAL MAY BE TAKEN. ...................................................................... ____________________________________________________ DATE JUDGE

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Form DC-632 ORDER OF SUPPORT (CIVIL) FOR Form DC-632 MEDIATION SUPPORT AGREEMENT


Data Elements

1. Insert court case number.

2. DCSE case identification number, if applicable.

3. Court name and type.

4. Name of petitioner.

5. Name of respondent.

6. Date of Mediation Support Agreement (form DC-631).

7. Date order entered.


Form DC-633 NOTICE OF ISSUANCE OF EMERGENCY Form DC-633 PROTECTIVE ORDER – FAMILY ABUSE


Using This Form

1. Copies

a. Original – to court. b. First copy – to allegedly abused person.

c. Second copy – to respondent.

2. Prepared and signed by law-enforcement officer. 3. Attachments

a. Form DC-653, SUPPLEMENTAL SHEET TO PROTECTIVE ORDER, if applicable.


a. This form should include the same terms and conditions as are on form DC-626, EMERGENCY PROTECTIVE ORDER – FAMILY ABUSE.

b. After serving the order, the officer completes the service of process portion,

including the description of the respondent.

c. The address and telephone number of the allegedly abused person should not be entered in the services box on the reverse side of this form. This information is to be kept confidential. District Court form DC-621, NONDISCLOSURE ADDENDUM, should be used to collect this information.



MO. DAY YR. FT. IN.

SSN


NOTICE OF ISSUANCE OF EMERGENCY Court Case No. .....................................................................

PROTECTIVE ORDER – FAMILY ABUSE Commonwealth of Virginia Va. Code §§ 16.1-253.4; 16.1-264 ................................................................................................................................................................................. Juvenile and Domestic Relations District Court

ALLEGEDLY ABUSED PERSON DATE OF BIRTH OF ALLEGEDLY ABUSED PERSON

LAST FIRST MIDDLE

V.


LAST FIRST MIDDLE ................................................................................................................................. RESPONDENT’S ADDRESS/LOCATION .................................................................................................................................

NOTICE TO RESPONDENT:

An Emergency Protective Order – Family Abuse was issued against you by a judge or magistrate on ............................................................................... DATE OF ISSUANCE

after the judge or magistrate made the following findings:

[ ] A warrant for a violation of § 18.2-57.2 has been issued and there is probable danger of further family abuse against ....................................................................................................................................................... by you; OR FAMILY OR HOUSEHOLD MEMBER

[ ] Reasonable grounds exist to believe that you have committed family abuse and there is probable danger of a further such offense against ....................................................................................................................................................... by you.

FAMILY OR HOUSEHOLD MEMBER

You have been ORDERED, by the terms of the Emergency Protective Order – Family Abuse, to observe the following conditions:

[ ] You shall not commit acts of family abuse or criminal offenses that result in injury to person or property.

[ ] You shall have no contact of any kind with .................................................................................................................................................................................... ..........................................................................................................................................................................................................................................................................

[ ] except as follows: ............................................................................................................................................................................................................................ .................................................................................................................................................................................................................................................................

[ ] The allegedly abused person is granted possession of the companion animal described as ........................................................................................... NAME/TYPE

[ ] ..............................................................................................................................................., the family or household member, is granted possession of the premises occupied by the parties, located at ................................................................................................................................................................................... ,

to the exclusion of you; however, no such grant of possession shall effect title to any real or personal property.

[ ] Conditions and/or information from Supplemental Sheet to Protective Order, DC-653 ................................................................................................... ............................................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

Receipt of this Notice by the Respondent from a law-enforcement officer shall be deemed to be personal service of the Emergency Protective Order – Family Abuse on the Respondent.

I personally provided this Notice to the Respondent. ....................................................................................... ____________________________________________________ DATE AND TIME OF ISSUANCE SIGNATURE OF LAW-ENFORCEMENT OFFICER

for _________________________________________________

RESPONDENT: SEE WARNINGS ON REVERSE

THE EMERGENCY PROTECTIVE ORDER EXPIRES ON ............................................................................ at 11:59 p.m. DATE


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1. Court case number. 2. Name of court.

3. Name of allegedly abused person.

4. Date of birth of allegedly abused person.


6. Address/location of respondent.


8. Check this box if a weapon has been involved in any of the previous altercations between

the parties.

9. Date of issuance of form DC-626, EMERGENCY PROTECTIVE ORDER.

10. Check appropriate box for basis of issuance of the Emergency Protective Order, and insert name of family or household member.

11. Check appropriate box(es) and insert information for conditions included in the

Emergency Protective Order – Family Abuse issued by the judicial officer.

12. Check this box and insert conditions and/or information from form DC-653, SUPPLEMENTAL SHEET TO PROTECTIVE ORDER, if applicable.

13. Expiration date of order.

14. Date and time form given to respondent.

15. Signature of serving law-enforcement officer.

16. Jurisdiction/agency of law-enforcement officer.

FORM DC-633 (REVERSE, PAGE ONE AND FOUR) 10/11

RETURNS: Each person was served according to law, as indicated below, unless not found.

RESPONDENT NAME ..................................................................................................................................... .................................................................................................................................................... ADDRESS .............................................................................................................................. ....................................................................................................................................................

ALLEDGLY ABUSED PERSON: (See form DC-621, NON-DISCLOSURE ADDENDUM) NAME ....................................................................................................................

[ ] PERSONAL SERVICE TELEPHONE NUMBER: ................................................................


[ ] NOT FOUND

[ ] NOT FOUND

__________________________________________________________

SERVING OFFICER

for ___________________________________________ ....................................................................................................................................................

DATE AND TIME

______________________________________________

SERVING OFFICER

for ___________________________________________ .....................................................................................................................................................

DATE AND TIME

Respondent’s Description (for VCIN entry):

RACE .................................. SEX .......................................................................

DOB: .......................................................................................................................................

HGT .................................... WGT .....................................................................................

EYES .................................. HAIR ....................................................................................

SSN ..........................................................................................................................................

Relationship to Petitioner/Plaintiff .............................................................................

Distinguishing features .....................................................................................................


..................................................................................................................................................... By .............................................................................................................................................

TITLE .....................................................................................................................................................

SIGNATURE

..................................................................... DATE

This order will be entered into the Virginia Criminal Information Network. The Respondent may at any time file a motion with the court requesting a hearing to dissolve or modify this order; however, this order remains in full force and effect unless and until dissolved or modified by the court. WARNINGS TO RESPONDENT: PURSUANT TO § 18.2-308.1:4, YOU SHALL NOT PURCHASE OR TRANSPORT ANY FIREARM WHILE THIS ORDER IS IN EFFECT. IF YOU HAVE A CONCEALED HANDGUN PERMIT, YOU MUST IMMEDIATELY SURRENDER THAT PERMIT TO THE COURT ISSUING THIS ORDER. IF YOU VIOLATE THE CONDITIONS OF THIS ORDER, YOU MAY BE SENTENCED TO JAIL AND/OR ORDERED TO PAY A FINE. DEFINITION OF TERMS USED IN THIS ORDER “Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person. A “law-enforcement officer” means any full-time or part-time employee of a police department or sheriff's office which is part of or administered by the Commonwealth or any political subdivision thereof, and who is responsible for the prevention and detection of crime and the enforcement of the penal, traffic or highway laws of this Commonwealth. Part-time employees are compensated officers who are not full-time employees as defined by the employing police department or sheriff’s office. “Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury.

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Data Elements, reverse

(pages 1 and 4)

1. Name of respondent. 2. Address of respondent.

3. Telephone number of respondent.






9. Identifying information of respondent (for VCIN entry).

10. Name of allegedly abused person. Do not include allegedly abused person’s address or

telephone information in the service box.






16. If copy delivered to allegedly abused person instead of being served, check box and insert the name of the person to whom a copy of the order was given.

17. Insert the title of the individual giving a copy of the order to the allegedly abused person.

18. Signature of individual giving a copy of the order to the allegedly abused person.


FORM DC-633 (REVERSE, PAGES TWO AND THREE) 10/11

DEFINITION OF TERMS USED IN THIS ORDER

“Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person.

A “law-enforcement officer” means any full-time or part-time employee of a police department or sheriff's office which is part of or administered by the Commonwealth or any political subdivision thereof, and who is responsible for the prevention and detection of crime and the enforcement of the penal, traffic or highway laws of this Commonwealth. Part-time employees are compensated officers who are not full-time employees as defined by the employing police department or sheriff’s office. “Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury.

This order will be entered into the Virginia Criminal Information Network. The Respondent may at any time file a motion with the court requesting a hearing to dissolve or modify this order; however, this order remains in full force and effect unless and until dissolved or modified by the court. WARNINGS TO RESPONDENT:

PURSUANT TO § 18.2-308.1:4, YOU SHALL NOT PURCHASE OR TRANSPORT ANY FIREARM WHILE THIS ORDER IS IN EFFECT. IF YOU HAVE A CONCEALED HANDGUN PERMIT, YOU MUST IMMEDIATELY SURRENDER THAT PERMIT TO THE COURT ISSUING THIS ORDER.

IF YOU VIOLATE THE CONDITIONS OF THIS ORDER, YOU MAY BE SENTENCED TO JAIL AND/OR ORDERED TO PAY A FINE.

Form DC-635 MOTION FOR SHOW CAUSE SUMMONS OR CAPIAS Page: 1

Using This Form

1. Copies


b. First copy – to defendant. 2. Prepared by petitioner. 3. Attachments

a. DC-360, SHOW CAUSE SUMMONS, or

b. DC-361, CAPIAS 4. Preparation details

a. This form may be used when charging someone with violating the terms of a court document (such as a witness ignoring a subpoena) or court order. Therefore, the subject of the Show Cause Summons process is called the Respondent.

b. Data Element No. 9 is not used for charging contempt for mere failure to comply with an

order. It is used for failure to comply with terms of a suspended sentence. For contempt for failure to comply with an order, use Data Elements Nos. 11 through 14.

c. This form should name both the surety (if any) and the principal when breach of bail

terms is alleged.

d. If the Respondent is not the defendant, this summons should be treated as a new case.

e. If additional information is to be typed on the reverse of the form, carbon paper must be inserted.

f. This form provides a formal mechanism for documenting complaints about violations of

court orders when a show cause summons is requested. It is not intended to supplement the ability of the court to issue show cause summons on its own motion.

DISTRICT COURT MANUAL FORMS VOLUME FEBRUARY 2009

Form DC-635 MOTION FOR SHOW CAUSE SUMMONS OR CAPIAS Page: 2 MOTION FOR SHOW CAUSE SUMMONS OR CAPIAS Case No. ................................................................................. 1

Commonwealth of Virginia ..................................................................................................... 2

HEARING DATE AND TIME


COMPLETE DATA BELOW IF KNOWN BORN HT. RACE SEX

MO. DAY YR. FT. IN.

WGT. EYES HAIR

SSN

.................................................................................................................................. Juvenile and Domestic Relations District Court 3

This motion is filed in connection with Case No. ..................................................................................................................................................................... 4

......................................................................................................................... v. / In re ....................................................................................................................... 5 Party making this Request: Party to be Served: ................................................................................................................... .................................................................................................................... 6 7 NAME NAME ................................................................................................................... .................................................................................................................... ADDRESS/LOCATION ADDRESS/LOCATION ................................................................................................................... .................................................................................................................... ................................................................................................................... .................................................................................................................... TELEPHONE NUMBER TELEPHONE NUMBER

The undersigned respectfully represents to the Court that the Respondent should, [ ] pursuant to Va. Code § 19.2-306, serve the sentence previously 9

8 suspended on .................................................................... for conviction of ........................................................................................................................................... because ............................................................................................ ................................................................................................................................................................................................................................................................

[ ] have his or her recognizance revoked or modified because of the following violation of conditions of release: ..................................

................................................................................................................................................................................................................................................................

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[ ] be imprisoned, fined or otherwise punished or dealt with according to law [ ] pursuant to Va. Code [ ] §§ 18.2-456/16.1-69.24 for failure to obey an order of [ ] this court [ ] .................................................. 1

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ordering .................................................................................................................................................................................................................................... 2

such act of the respondent being described as .................................................................................................................... on .............................. DATE

[ ] pursuant to Va. Code [ ] §§ 18.2-456/16.1-69.24 [ ] § 19.2-358 [ ] § 19.2-305.2 (restitution only), for failure to pay 13

fines, costs, forfeitures, restitution and/or penalties or an installment thereof; payment due: $ ....................... on ........................... DATE

[ ] pursuant to Va. Code § 16.1-278.16 for failure to provide support as ordered on 14

........................................................................ $ ..................................................... per ......................................................................... DATE

with $ .................................................................. arrearage as of ...................................................... DATE

[ ] pursuant to § 19.2-303.3, have his or her local community-based probation revoked or modified because ............................................

................................................................................................................................................................................................................................................................

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[ ] pursuant to § 19.2-304, have his or her probation period or conditions modified as follows: .......................................................................

................................................................................................................................................................................................................................................................

because ..............................................................................................................................................................................................................................................

[ ] pursuant to [ ] § 4.1-305 [ ] § 18.2-57.3 [ ] § 18.2-251 [ ] § 19.2-303.2, have his or her deferral of proceedings revoked and

subjected to the proceedings as provided by law because ............................................................................................................................................

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[ ] (Other – Explain) ........................................................................................................................................................................................................................

........................................................................................................................................................................................................................ 17

Therefore, the undersigned requests the issuances of process to the respondent to answer the above motion.

............................................. ............................................................................................. ____________________________________________________ 18 19 20

DATE TITLE SIGNATURE FORM DC-635 REVISED 10/08

Form DC-635 MOTION FOR SHOW CAUSE SUMMONS OR CAPIAS Page: 3


Data Elements 1. Court case number. 2. Hearing date and time. 3. Court name. 4. Case number of underlying case. 5. Name of underlying case. 6. Name, street address and telephone

number of party making request. 7. Name, street address and telephone

number of party to be served. 8. Description of the party to be served. 9. If violation of conditions of suspended

sentence is alleged, check this box, insert date of sentence suspended, conviction, and insert a description of the alleged violation of conditions. See Using This Form, 4.b.

10. If breach of bail conditions is alleged,

check this box, insert name of person released on bail, and insert a description of the alleged breach of bail conditions. See Using This Form, 4.c.

11. Check this box if any of the Data

Elements Nos. 12 through 15 is checked. 12. If respondent allegedly failed to obey

some other type of order not covered by other data elements, check this box, (if applicable) name the court whose order was violated, and describe the terms of the order that were allegedly violated.

13. If respondent allegedly failed to make a

timely payment, check this box, and insert the amount of the payment due and its due date.

14. If respondent allegedly failed to pay support, check this box and insert the date support was ordered, the amount of current support, the type of payment interval, the arrearage, and the date to which the arrearage is calculated.

15. If respondent has allegedly violated

conditions of probation, check the box and describe the violation.

16. If respondent has allegedly violated

conditions of order for deferral, check the box and describe the violation.

17. Check this box and complete this section

if other reasons exist for the issuance of a show cause summons or capias. If needed, continue on reverse side. See Using This Form, 4.e.

18. Date of signing of motion. 19. Title of person seeking the show cause. 20. Signature of person seeking the show

cause.

Form DC-637 CHILD SUPPORT GUIDELINES WORKSHEET Page: 1

Using This Form 1. Copies – original - to court file.

2. Prepared by judge, clerk, intake officer, attorney, or employee of Division of Child Support

Enforcement. See Preparation Details below.


4. Preparation Details –

a. This form may be used in both circuit court cases and juvenile and domestic relations district court cases in which child support is at issue.

b. This form is designed for use with the guidelines calculations provisions and procedures required by Virginia Code § 20-108.2.

c. In completing Data Element Nos. 5 through 10, do not substitute data about a non-parental custodian who is a party for data about a parent who is not a party.

d. Data Element No. 18 – if applicable, the amount is deducted only in the column for the non-custodial parent.

e. More detailed instructions for completing the form can be found on page two of the form.


Form DC-637 CHILD SUPPORT GUIDELINES WORKSHEET Page: 2 CHILD SUPPORT GUIDELINES WORKSHEET Case No. ...............................................................................................................

1 Commonwealth of Virginia Va. Code § 20-108.2 ........................................................................................................................................................... v. ................................................................................................................................................... ..................................................... DATE

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MOTHER FATHER

1. Monthly Gross Income (see instructions on reverse) $ .......................................... $ ................................................


2. Adjustments for spousal support payments (see instructions on reverse) $ .......................................... $ ................................................

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6 3. Adjustments for support of child(ren) (see instructions on reverse) $ .......................................... $ ................................................

4. Deductions from Monthly Gross Income allowable by law $ .......................................... $ ................................................

(see instructions on reverse)

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5. a. Available monthly income $ .......................................... $ ................................................

9 b. Combined monthly available income (combine both available monthly income figures from line 5.a.) $

6. Number of children in the present case for whom support is sought: 7. a. Monthly basic child support obligation (from schedule — see instructions on reverse) a. $ ................................................... b. Monthly amount allowable for health care coverage b. $ ................................................... (see instructions on reverse) c. Monthly amount allowable for employment-related child care expenses c. $ ................................................... (see instructions on reverse) 8. Total monthly child support obligation (add lines 7.a., 7.b., and 7.c.) $

MOTHER FATHER

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9. Percent obligation of each party (divide “available monthly income” on ...............................................% ................................................ % line 5.a. by line 5.b.)

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10. Monthly child support obligation of each party (multiply line 8 by line 9) $ $

17 11. Deduction by non-custodial parent for health care coverage when paid directly by non-custodial parent or non-custodial parent’s spouse (from line 7.b.) $ .......................................... $ ..........................................

MOTHER FATHER

12. Adjustments (if any) to Child Support Guidelines Calculation (see instructions on reverse)

a. Credit for benefits received by or for the child derived from the parent’s -$ ......................................... -$ .............................................. entitlement to disability insurance benefits to the extent that such derivative benefits are included in a parent’s gross income

b. .................................................................................................................................................................................................... $ .......................................... $ .............................................

c. ................................................................................................................................................................................................... $ .......................................... $ .............................................

13. Each party’s adjusted share $ $

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21 FORM DC-637 (MASTER, PAGE ONE OF TWO) 07/09

Form DC-637 CHILD SUPPORT GUIDELINES WORKSHEET Page: 3


Data Elements 1. Court case number. 2. Name of petitioner/plaintiff. 3. Name of respondent/defendant. 4. Date on which this form was completed. 5. Monthly Gross Income of the mother and of

the father. See Using This Form, 4.c., and the instructions on the back of the form.

6. Adjustments for spousal support payments.

See Using This Form, 4.c., and the instructions on the back of the form.

7. Adjustments for support of child (ren) other

than the child (ren) that are the subject of the present proceeding. See Using This Form, 4.c., and the instructions on the back of the form.

8. Deductions for certain expenses incurred in

earnings of a sole proprietorship, a partnership or a closely held business and one-half of self-employment taxes. See Using This Form, 4.c., and the instructions on the back of the form.

9. Available monthly income of each parent.

See Using This Form, 4.c., and instructions on the back of the form.

10. Combined available monthly income of both

parents. 11. Total number of children for whom support

is requested. 12. Guidelines calculation of suggested monthly

basic child support obligation. See the instructions on the back of the form.

13. Additional amount required for health care coverage of the child(ren). See the instructions on the back of the form.

14. Additional amount required for

employment-related child care. See the instructions on the back of this form.

15. Total amount of child support to be provided

by both father and mother. 16. Percentage of the total amount of child

support to be paid by each parent. 17. Amount of child support for which each

parent has a responsibility. 18. Amount to be deducted only by the non-

custodial parent for direct payment of health care coverage. See the instructions on the back of the form. Omit if not applicable. See Using This Form, 4.d.

19. Insert deduction if applicable. See

instructions on reverse of form. 20. Describe reasons for additional adjustments

to calculations made pursuant to the child support guidelines calculation procedures and the amount of such adjustments. See instructions on the back of the form. Omit if not applicable.

21. Amount of each parent's child support

obligation as adjusted by amounts in Data Element Nos. 19 and 20.

Form DC-637 CHILD SUPPORT GUIDELINES WORKSHEET Page: 4 CHILD SUPPORT GUIDELINES WORKSHEET INSTRUCTIONS

General — Use monthly financial information rounded to the nearest dollar in making these calculations. To convert data to monthly figures, • multiply weekly financial data by 4.33 • multiply bi-weekly financial data by 2.167 • multiply semi-monthly financial data by 2 • divide annual financial data by 12

Amounts of $.50 or more should be rounded up to the nearest dollar; amounts less than $.50 should be rounded down to the nearest dollar.

Line 1 — Gross income is defined by Virginia Code § 20-108.2(C).

a. Gross income “shall mean all income from all sources, and shall include, but not be limited to, income from salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital gains, social security benefits, worker’s compensation benefits, disability insurance benefits, veterans’ benefits, spousal support, rental income, gifts, prizes or awards. If a parent’s gross income includes disability insurance benefits, it shall also include any amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits.”

b. Gross income “shall not include benefits from public assistance programs as defined in Virginia Code § 63.2-100 [Temporary Assistance to Needy

Families, auxiliary grants to the aged, blind and disabled, medical assistance, energy assistance, food stamps, employment services, child care, general relief] federal Supplemental Security benefits, child support received, or income received by the payor from secondary employment income not previously included in “gross income,” where the payor obtained the income to discharge a child support arrearage established by a court or administrative order and the payor is paying the arrearage pursuant to the order.”

Line 2 — If spousal support is being paid by a party pursuant to an existing court or administrative order or written agreement, regardless of whether it is being paid to the other party or to a person not a party to this proceeding, subtract that amount under the payor’s column. If spousal support is being received by a party pursuant to an existing court or administrative order or written agreement, regardless of whether it is being paid by the other party to this proceeding, add the amount under the payee’s column. Use plus and minus signs appropriately. If a party is not paying or receiving spousal support, insert “none” in the appropriate column(s). Line 3 — When a party is paying child support payments pursuant to an existing court or administrative order or written agreement for a child or children who are not the subject of the proceeding, subtract this amount from gross income. When a party has a child or children who are not the subject of the proceeding in their household or primary physical custody, subtract the amount as shown on the schedule of Monthly Basic Child Support Obligations that represents that party’s support obligation for that child or children based solely on the party’s income as the total income available. If these provisions are inapplicable, insert “none” in the appropriate column(s). There is only a presumption that these amounts will be deducted from gross income. Line 4 (Virginia Code § 20-108.2(C)) — If either parent has income from self-employment, a partnership or a closely-held business, subtract reasonable business expenses under the column of the party with such income. Include one-half of any self-employment tax paid, if applicable. If none, insert “none.” Line 5.a. — As applicable, add to and subtract from line 1 the figures in lines 2, 3 and 4 and enter the total for each column. NOTE: Any adjustments to gross income shall not create or reduce a support obligation to an amount which seriously impairs the custodial parent’s ability to maintain minimal adequate housing and provide other basic necessities for the child. Line 7.a. — Using § 20-108.2(B) SCHEDULE OF MONTHLY BASIC CHILD SUPPORT OBLIGATIONS, use line 5.b. (combined monthly available income) to find the applicable income level under COMBINED GROSS INCOME, then use line 6 (number of children) to determine the basic child support obligation under the appropriate column at the applicable income level. Line 7.b. (Virginia Code §§ 20-108.2(E) and 63.2-1900) — Insert costs for “health care coverage” when actually being paid by a parent or that parent’s spouse, to the extent such costs are directly allocable to the child or children, and which are the extra costs of covering the child or children beyond whatever coverage the parent or that parent’s spouse providing the coverage would otherwise have. “Health care coverage” means any plan providing hospital, medical or surgical care coverage for dependent children provided such coverage is available and can be obtained by a parent, parents, or a parent’s spouse at a “reasonable cost” (defined as “available, in an amount not to exceed 5% of the parents’ combined gross income, and accessible through employers, unions or other groups, or Department-sponsored health care coverage, without regard to service delivery mechanism”). This item should also include the cost of any dental care coverage for the child or children paid by a parent, or that parent’s spouse. Lines 7.c. (Virginia Code § 20-108.2(F)) — Insert actual cost or the amount required to provide quality child care, whichever is less. If applicable, allocate ratably between employment-related child care and other child care based on custodian’s activities while child care is being provided. Line 12(a) — If amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits have been included in a parent’s gross income, that amount should be subtracted from that parent’s child support obligation. Line 12 (b-c) (Virginia Code § 20-108.1(B)) — If applicable, describe adjustment to child support for factors not addressed in guidelines calculation, then show amount to be added to or subtracted from each party-parent’s child support obligation (use plus and minus signs appropriately). Line 13— If additional items are entered in lines 12 (a-c), add and subtract such items from line 10 and enter the totals on this line. In cases involving split custody, the amount of child support to be calculated using these guidelines shall be the difference between the amounts owed by each parent as a noncustodial parent, computed in accordance with these guidelines, with the noncustodial parent owing the larger amount paying the difference to the other parent. For the purpose of applying these provisions, split custody shall be limited to those situations where each parent has physical custody of a child or children born of the parents, born of either parent and adopted by the other parent or adopted by both parents. For the purposes of calculating a child support obligation where split custody exists, a separate family unit exists for each parent, and child support for that family unit shall be calculated upon the number of children in that family unit who are born of the parents, born of either parent and adopted by the other parent or adopted by both parents. Where split custody exists, a parent is a custodial parent to the children in that parent’s family unit and is a noncustodial parent to the children in the other parent’s family unit. FORM DC-637 (MASTER, PAGE TWO OF TWO) 05/10


Form DC-638 CHILD SUPPORT GUIDELINES WORKSHEET – Page: 1 PLIT USTODYS C


Using This Form

1. Copies – original – to court file. 2. Prepared by judge, clerk, intake officer, attorney, or employee of Division of Child

Support Enforcement. See Preparation Details below.


4. Preparation details –

a. This form may be used to calculate and document the calculation of each parent's support obligation in cases of split custody in both circuit court cases and juvenile and domestic relations district court cases in which child support is at issue.

b. This form is designed for use with the guidelines calculations provisions and

procedures required by Virginia Code § 20-108.2.

c. In completing Data Element Nos. 5 through 10, do not substitute data about a non-parental custodian who is a party for data about a parent who is not a party.

d. More detailed instructions for completing the form can be found on page two of the

form.

Form DC-638 CHILD SUPPORT GUIDELINES WORKSHEET – Page: 2 SPLIT CUSTODY


CHILD SUPPORT GUIDELINES WORKSHEET ― SPLIT CUSTODY Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 Commonwealth of Virginia Va. Code § 20-108.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DATE

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MOTHER FATHER

1. Monthly Gross Income (see instructions on Page 2) $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . . . . . . . . . . . . . . . . .

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5 2. Adjustments for spousal support payments (see instructions on Page 2) $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . .

3. Adjustments for support of child(ren) (see instructions on Page 2) $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . .

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4. Deductions from Monthly Gross Income allowable by law -$ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . 8 8 (see instructions on Page 2)

5. a. Available monthly income $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . .

b. Combined monthly available income (combine both available monthly income figures from line 5.a.) $

6. Percent obligation of each party (divide “available monthly income” on line Line 5.a. by line 5.b.) % . . . . . . . . . . . . . . . . . . . . . . . . . . % . . . . . . . . . . . . . . . . . . . . . . .

7. Number of children for which that person is the noncustodial parent. MOTHER FATHER 8. a. Monthly basic child support obligation for number of children listed above (from schedule — see instructions on Page 2) $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . b. Monthly amount allowable for health care coverage paid by other parent $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . or that other parent’s spouse (see instructions on Page 2) c. Monthly amount allowable for employment-related child care expense paid $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . by other parent (see instructions on Page 2) 9. Total monthly child support obligation of each parent (add lines 8.a., $ $ 8.b., and 8.c. for each parent) 10. Total monthly child support obligation of each party (multiply line 6 by line 9) $ $ wo)

MOTHER FATHER 11. Adjustments (if any) to Child Support Guidelines Calculation (see instructions on Page 2)

a. Credit for benefits received by or for the child derived from the parent’s -$ . . . . . . . . . . . . . . . . . . . . . . . . . . . -$ . . . . . . . . . . . . . . . . . . . . . . entitlement to disability insurance benefits to the extent that such derivative benefits are included in a parent’s gross income b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . .

c. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . 12. Each party’s adjusted obligation to other party $ $ 13. Net payment $ $

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Data Elements

1. Court case number. 2. Name of the party asking for the hearing on support. 3. Name of other parent of the child/children. 4. Date on which this form is completed. 5. Monthly gross income of the mother and the father. 6. Each parent's adjustments for spousal support. 7. Each parent's adjustments for support of child (ren) other than the children that are the subject of the

present proceeding. 8. Allowable deductions from monthly income. Deductions described on page two of the form. 9. Available monthly income of each parent from Data Element Nos. 5 through 8. 10. Combined available monthly income of both parents. 11. Divide Data Element No. 9 by Data Element No. 10 for each parent and enter percentage. 12. Number of children not in custody of the mother. 13. Number of children not in custody of the father. 14. Support obligation of each parent (see page two of form for instructions). 15. Amount of health care coverage paid by each parent or each parent’s spouse. 16. Amount of child care expense paid by each parent. 17. Add Data Element Nos. 14-16 (lines 8.a., 8.b. and 8.c.) for each parent. 18. Multiply Data Element No. 11 (line 6) by Data Element No. 17 (line 9) for each parent. 19. Insert deduction if applicable. 20. Enter amount of and reasons for any adjustments. 21. Enter adjusted obligation for each parent by subtracting Data Element Nos. 19 and 20(lines 11.a., b.

and c.) from Data Element No. 18 (line 10). 22. Net payment of each parent.


CHILD SUPPORT GUIDELINES WORKSHEET INSTRUCTIONS For the purpose of applying this provision, split custody shall be limited to those situations where each parent has physical custody of a child or children born of the parents, born of either parent and adopted by the other parent or adopted by both parents. For the purposes of calculating a child support obligation where split custody exists, a separate family unit exists for each parent, and child support for that family unit shall be calculated upon the number of children in that family unit who are born of the parents, born of either parent and adopted by the other parent or adopted by both parents. Where split custody exists, a parent is a custodial parent to the children in that parent’s family unit and is a noncustodial parent to the children in the other parent’s family unit.

General — Use monthly financial information rounded to the nearest dollar in making these calculations. To convert data to monthly figures,

• multiply weekly financial data by 4.33 • multiply bi-weekly financial data by 2.167 • multiply semi-monthly financial data by 2 • divide annual financial data by 12

Amounts of $.50 or more should be rounded up to the nearest dollar; amounts less than $.50 should be rounded down to the nearest dollar.

Line 1 — Gross income is defined by Virginia Code § 20-108.2(C).

a. Gross income “shall mean all income from all sources, and shall include, but not be limited to, income from salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital gains, social security benefits, worker’s compensation benefits, disability insurance benefits, veterans’ benefits, spousal support, rental income, gifts, prizes or awards. If a parent’s gross income includes disability insurance benefits, it shall also include any amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits.”

b. Gross income “shall not include benefits from public assistance programs as defined in Virginia Code § 63.2-100 [Temporary Assistance to Needy Families, auxiliary grants to the aged, blind and disabled, medical assistance, energy assistance, food stamps, employment services, child care, general relief] federal Supplemental Security benefits, child support received, or income received by the payor from secondary employment income not previously included in “gross income,” where the payor obtained the income to discharge a child support arrearage established by a court or administrative order and the payor is paying the arrearage pursuant to the order.”

Line 2 —If spousal support is being paid by a party pursuant to an existing court or administrative order or written agreement, regardless of whether it is being paid to the other party or to a person not a party to this proceeding, subtract that amount under the payor’s column. If spousal support is being received by a party pursuant to an existing court or administrative order or written agreement, regardless of whether it is being paid by the other party to this proceeding, add the amount under the payee’s column. Use plus and minus signs appropriately. If a party is not paying or receiving spousal support, insert “none” in the appropriate column(s).

Line 3 —When a party is paying child support payments pursuant to an existing court or administrative order or written agreement for a child or children who are not the subject of the proceeding, subtract this amount from gross income. When a party has a child or children who are not the subject of the proceeding in their household or primary physical custody, subtract the amount as shown on the Schedule of Monthly Basic Child Support Obligations that represents that party’s support obligation for that child or children based solely on that party’s income as the total income available. If these provisions are inapplicable, insert “none” in the appropriate column(s). There is only a presumption that these amounts will be deducted from gross income.

Line 4 (Virginia Code § 20-108.2(C)) — If either parent has income from self-employment, a partnership or a closely-held business, subtract reasonable business expenses under the column of the party with such income. Include one-half of any self-employment tax paid, if applicable. If none, insert “none.”

Line 5.a. — As applicable, add to and subtract from line 1 the figures in lines 2, 3 and 4 and enter the total for each column.

NOTE: Any adjustments to gross income shall not create or reduce a support obligation to an amount which seriously impairs the custodial parent’s ability to maintain minimal adequate housing and provide other basic necessities for the child.

Line 8.a. — Using Virginia Code § 20-108.2(B) SCHEDULE OF MONTHLY BASIC CHILD SUPPORT OBLIGATIONS, use line 5.b. (combined monthly available income) to find the applicable income level under COMBINED GROSS INCOME, then use line 7 (number of children) to determine the basic child support obligation under the appropriate column at the applicable income level.

Line 8.b. (Virginia Code §§ 20-108.2(E) and 63.2-1900) — Insert costs for “health care coverage” when actually being paid by a parent or that parent’s spouse, to the extent such costs are directly allocable to the child or children, and which are the extra costs of covering the child or children beyond whatever coverage the parent or that parent’s spouse providing the coverage would otherwise have. “Health care coverage” means any plan providing hospital, medical or surgical care coverage for dependent children provided such coverage is available and can be obtained by a parent, parents, or a parent’s spouse at a “reasonable cost” (defined as “available, in an amount not to exceed 5% of the parents’ combined gross income, and accessible through employers, unions or other groups without regard to service delivery mechanism”). This item should also include the cost of any dental coverage for the child or children paid by a parent or that parent’s spouse.

Lines 8.c. (Virginia Code § 20-108.2(F)) — Insert actual cost or the amount required to provide quality child care, whichever is less. If applicable, allocate ratably between employment-related child care and other child care based on custodian’s activities while child care is being provided.

Line 11 (a-c) (Virginia Code § 20-108.1(B)) If amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits have been included in a parent’s gross income, that amount should be subtracted from that parent’s child support obligation. If applicable, describe adjustment to child support for factors not addressed in guidelines calculation, then show amount to be added to or subtracted from each party-parent’s child support obligation (use plus and minus signs appropriately).

Line 12 — If additional items are entered in lines 11 (a-c), add and subtract such items from line 10 and enter the totals on this line. In cases involving split custody, the amount of child support to be calculated using these guidelines shall be the difference between the amounts owed by each parent as a noncustodial parent, computed in accordance with these guidelines, with the noncustodial parent owing the larger amount paying the difference to the other parent. FORM DC-638 (MASTER, PAGE TWO OF TWO) 07/09


Form DC-639 CHILD SUPPORT GUIDELINES EXCEPTION Form DC-639 SUPPLEMENTAL TO ORDER OF SUPPORT


Using This Form

1. Copies – one for each copy of the support order to which it is attached.

2. Prepared by the judge or the clerk who is preparing the order for support.

3. Attachments

a. District court form DC-628, ORDER OF SUPPORT (CIVIL).

b. District court form DC-629, ORDER OF SUPPORT (CRIMINAL).

4. Preparation details – none.


CHILD SUPPORT GUIDELINES EXCEPTION Case No. ...................................................................................... SUPPLEMENT TO ORDER FOR SUPPORT Commonwealth of Virginia VA. CODE § 20-108.1 (Check and complete the applicable provisions.) a. [ ] Actual monetary SUPPORT FOR OTHER family members or former family members, Va. Code § 20-108.1 (B)(1)

b. [ ] Arrangements regarding CUSTODY of the children, including the cost of visitation travel, Va. Code § 20-108.1 (B)(2)

c. [ ] SUPPORT AGREEMENT by the parties

d. [ ] INCOME IMPUTED to a party who is voluntarily unemployed or voluntarily underemployed; provided that income may not be imputed to a custodial parent when a child is not in school, child care services are not available and the cost of such child care services are not included in the computation and provided further, that any consideration of imputed income based on a change in a party’s employment shall be evaluated with consideration of the good faith and reasonableness of employment decisions made by the party, including to attend and complete an educational or vocational program likely to maintain or increase the party’s earning potential, Va. Code § 20-108.1(B)(3)

e. [ ] Any CHILD CARE COSTS incurred on behalf of the child or children due to the attendance of a custodial parent in an educational or vocational program likely to maintain or increase the party’s earning potential, Va. Code § 20-108.1(B)(4)

f. [ ] DEBTS of either party arising during the marriage for the BENEFIT OF THE CHILD, Va. Code § 20.108.1(B)(5)

g. [ ] Direct payments ordered by the court for maintaining life insurance coverage, education expenses, or other COURT-ORDERED DIRECT PAYMENTS for the benefit of the child, Va. Code § 20-108.1(B)(6)

h. [ ] EXTRAORDINARY CAPITAL GAINS such as capital gains resulting from the sale of the marital abode, Va. Code § 20-108.1(B)(7)

i. [ ] Any SPECIAL NEEDS OF A CHILD resulting from any physical, emotional, or medical condition, Va. Code § 20-108.1(B)(8)

j. [ ] The INDEPENDENT FINANCIAL RESOURCES of the CHILD or children, Va. Code § 20-108.1(B)(9)

k. [ ] The STANDARD OF LIVING for the child or children established during the marriage, Va. Code § 20-108.1(B)(10)

l. [ ] The earning capacity, obligations, financial RESOURCES AND SPECIAL NEEDS OF EACH PARENT, Va. Code § 20-108.1(B)(11)

m. [ ] The PROVISIONS made with regard to the MARITAL PROPERTY under Va. Code § 20-107.3 where said property earns income or has income-earning potential, Va. Code § 20-108.1(B)(12)

n. [ ] Tax consequences to the parties including claims for exemptions, child tax credit, and child care credit for dependent children, Va. Code § 20-108.1(B)(13)

o. [ ] Limited by PLEADINGS

p. [ ] A written agreement, stipulation, consent, order, or decree between the parties which includes the amount of child support, Va. Code § 20-108.1(B)(14)

q. [ ] Such OTHER FACTORS as are necessary to consider the equities for the parents and children (Va. Code § 20-108.1 (B)(15) – describe briefly)

........................................................................................................................................................................................................................................................................ ........................................................................................................................................................................................................................................................................ ........................................................................................................................................................................................................................................................................ ........................................................................................................................................................................................................................................................................

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Form DC-639 CHILD SUPPORT GUIDELINES EXCEPTION Form DC-639 SUPPLEMENTAL TO ORDER OF SUPPORT


Data Elements


2. Check the applicable box(es) and, if applicable, insert a description of the reasons for the exception.

Form DC-640 CHILD SUPPORT GUIDELINES WORKSHEET – Form DC-640 SHARED CUSTODY


Using This Form

1. Copies – original – to court file. 2. Prepared by judge, clerk, intake officer, attorney, or employee of Division of Child

Support Enforcement. See Preparation Details below.


4. Preparation Details –

a. This form may be used to calculate and document the calculation of each parent's support obligation in cases of shared custody in both circuit court cases and juvenile and domestic relations district court cases in which child support is at issue.

b. This form is designed for use with the guidelines calculations provisions and procedures required by Virginia Code § 20-108.2.

c. Do not substitute data about a non-parental custodian who is a party for data about a parent who is not a party.

d. More detailed instructions for completing the form can be found on page two of the form.

CHILD SUPPORT GUIDELINES WORKSHEET – Case No. .......................................................................... SHARED CUSTODY Commonwealth of Virginia Va. Code § 20-108.2 ....................................................................................... v. .................................................................................... ................................................................ DATE

I. GUIDELINE CALCULATION Mother Father Combined

A. INCOME Monthly Gross Income (see instructions on Page 2) (1) $ ................................ (2) $ ................................ Adjustments for spousal support payments (see instructions on Page 2) (3) $ ................................ (4) $ ................................ Adjustments for support of child(ren) (see instructions on Page 2) (5) $ ................................ (6) $ ................................ Deductions from Monthly Gross Income Allowable by law (see instructions on Page 2) (7) $ ................................ (8) $ ................................ ______________________ ____________________

Available Gross Income (9) $ ................................ (10) $ .................................. = (11) $ ................................ Percentage of Combined Gross Income (12) $ ............................... (13) $ .................................. = 100%

B. CHILD SUPPORT NEEDS Number of child for whom support is sought (14) ........................................

Child support from guideline table – apply lines (11) and (14) to table (15) $ .....................................

Total shared support – line (15) x 1.40 (16) $ ..................................... Mother Father

Total days in year each parent has custody (17) .................................. (18) ..................................... = 365

Each parent’s custody share (19) .................................. % (20) ..................................... % = 100%

C. EACH PARENT’S SUPPORT OBLIGATION TO OTHER PARENT 1. Father’s obligation to Mother Mother Father

Basic support to Mother – lines (19) x (16) (21) $ .................................. Health care coverage PAID by Mother

or by Mother’s spouse (if any) (22) $ .................................. Work-related child care of Mother (if any) (23) $ .................................. Total – lines (21) + (22) + (23) (24) $ .................................. Father’s obligation – lines (24) x (13) = (25) $ ..................................

2. Mother’s obligation to Father Basic support to Father – lines (20) x (16) (26) $ ............................... Health care coverage PAID by Father

or by Father’s spouse (if any) (27) $ ............................... Work-related child care of Father (if any) (28) $ ............................... Total – lines (26) + (27) + (28) (29) $ ............................... Mother’s obligation – lines (29) x (12) = (30) $ ...............................

D. NET MONTHLY CHILD SUPPORT PAYABLE FROM ONE PARENT TO THE OTHER Shared custody child support guideline amount – difference between lines (25) and (30) = (31) (31) $ ..................................... (32) Payable to [ ] Mother [ ] Father (see instructions on Page 2)

II. ADJUSTMENTS (IF ANY) TO SHARED CUSTODY CHILD SUPPORT GUIDELINE AMOUNT

A. ADJUSTMENT ITEMS Mother Father 1. Credit for benefits received by or for the child

derived from the parent’s entitlement to disability insurance benefits to the extent that such derivative benefits are included in a parent’s gross income (33) $ ............................... (34) $ ..................................

2. ..................................................................................... $ ............................... $ .................................. 3. ..................................................................................... $ ............................... $ .................................. Total adjustments (35) $ ............................... (36) $ .................................. Net adjustments (difference between lines (35) and (36) (37) $ ........................................ (38) Owed to [ ] Mother [ ] Father (see instructions on Page 2)

B. TOTAL ADJUSTED SUPPORT (see instructions on Page 2) (39) $ ........................................ (40) Payable to [ ] Mother [ ] Father


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Form DC-640 CHILD SUPPORT GUIDELINES WORKSHEET – Form DC-640 SHARED CUSTODY


Data Elements 1. Court case number. 2. Name of party initiating the hearing. 3. Name of the party not initiating the hearing. 4. Hearing date. 5. Mother's monthly gross income. 6. Father's monthly gross income. 7. Each parent's adjustments for spousal support.

See instructions on the second page of the form. 8. Each parent's adjustments for support of

child(ren) other than the children that are the subject of the present proceeding. See instructions on the second page of the form.

9. Allowable deductions from monthly income.

Deductions are described on page two of the form.

10. Mother's available gross income. 11. Father's available gross income. 12. Total amount of income available for both

parents. 13. Divide Data Element No. 10 by Data Element

No. 12 for mother’s percentage of combined gross income. Once the percentage for one parent is entered, the form will calculate the percentage for the other parent.

14. Divide Data Element No. 11 by Data Element

No. 12 for father’s percentage of combined gross income. Once the percentage for one parent is entered, the form will calculate the percentage for the other parent.

15. Number of children for whom support is sought. 16. Amount of support pursuant to the guidelines. 17. Total shared support. 18. Number of days mother has custody per year. 19. Number of days father has custody per year. 20. Determine the percentage that each parent has

custody by dividing the number of days each parent has custody by 365. Once the percentage for one parent is entered, the form will calculate the percentage for the other parent.

21. Portion of the basic child support amount attributable to father. Multiply the percentage of time the mother has custody (Data Element No. 20) by the amount of total share support (Data Element No. 17).

22. If applicable, amount of health care coverage

actually paid by mother or by mother’s spouse if the amount can be directly allocated to the child(ren).

23. If applicable, amount of child care expense paid

by mother. 24. Total of Data Element Nos. 21, 22 and 23. 25. Multiply the total in Data Element No. 24 by the

percentage of the amount of total income made by the father (Data Element No. 14).

26. Portion of the basic child support amount

attributable to mother. Multiply the percentage of time the father has custody (Data Element No. 20) by the amount of total shared support (Data Element No. 17).

27. If applicable, amount of health care coverage

actually paid by father or by father’s spouse if the amount can be directly allocated to the child(ren).

28. If applicable, amount of child care expense paid

by father. 29. Total of Data Element Nos. 26, 27 and 28. 30. Multiply the total in Data Element No. 29 by the

percentage of the amount of total income made by the mother (Data Element No. 13).

31. Enter the difference between Data Element

Nos. 25 and 30, and check the party to whom support is payable.

32. Insert deduction, if applicable. 33. Adjustments to obligation. 34. Net adjustments (see "Instructions"). 35. Enter adjusted amount owed and check box to

indicate to whom the support is payable.

CHILD SUPPORT GUIDELINES WORKSHEET INSTRUCTIONS General — Use monthly financial information rounded to the nearest dollar in making these calculations. To convert data to monthly figures, • multiply weekly financial data by 4.33 • multiply bi-weekly financial data by 2.167 • multiply semi-monthly financial data by 2 • divide annual financial data by 12

Amounts of $.50 or more should be rounded up to the nearest dollar; amounts less than $.50 should be rounded down to the nearest dollar. Lines 1 and 2 — Gross income is defined by Virginia Code § 20-108.2(C). a. Gross income “shall mean all income from all sources, and shall include, but not be limited to, income from salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital gains, social security benefits, worker’s compensation benefits, disability insurance benefits, veterans’ benefits, spousal support, rental income, gifts, prizes or awards. If a parent’s gross income includes disability insurance benefits, it shall also include any amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits.” b. Gross income “shall not include benefits from public assistance programs as defined in Virginia Code § 63.2-100 [Temporary Assistance to Needy Families, auxiliary grants to the aged, blind and disabled, medical assistance, energy assistance, food stamps, employment services, child care, general relief] federal Supplemental Security benefits, child support received, or income received by the payor from secondary employment income not previously included in “gross income,” where the payor obtained the income to discharge a child support arrearage established by a court or administrative order and the payor is paying the arrearage pursuant to the order.” Lines 3 and 4 — If spousal support is paid by a party pursuant to an existing court or administrative order or written agreement, regardless of whether it is being paid to the other party or to a person not a party to this proceeding, subtract that amount under the payor’s column. If spousal support is being received by a party pursuant to an existing court or administrative order or written agreement, regardless of whether it is being paid by the other party to this proceeding, add the amount under the payee’s column. Use plus and minus signs appropriately. If a party is not paying or receiving spousal support, insert “none” in the appropriate column(s). Lines 5 and 6 - When a party is paying child support payments pursuant to an existing court or administrative order or written agreement for a child or children who are not the subject of the proceeding, subtract this amount from gross income. When a party has a child or children who are not the subject of the proceeding in their household or primary physical custody, subtract the amount as shown on the Schedule of Monthly Basic Child Support Obligations that represents that party’s support obligation for that child or children based solely on that party’s income as the total income available. If these provisions are inapplicable, insert “none” in the appropriate column(s). There is only a presumption that these amounts will be deducted from gross income. Line 7 and 8 (Virginia Code § 20-108.2(C)) — If either parent has income from self-employment, a partnership or a closely-held business, subtract reasonable business expenses under the column of the party with such income. Include one-half of self-employment tax paid, if applicable. If none, insert “none.” NOTE: Any adjustments to gross income shall not create or reduce a support obligation to an amount which seriously impairs the custodial parent’s ability to maintain minimal adequate housing and provide other basic necessities for the child. Line 15 — Using Virginia Code § 20-108.2(B) SCHEDULE OF MONTHLY BASIC CHILD SUPPORT OBLIGATIONS, use line (11) (combined monthly available income) to find the applicable income level under COMBINED GROSS INCOME, then use line (14) (number of children) to determine the basic child support obligation under the appropriate column at the applicable income level. Line 22 and 27— (Virginia Code §§ 20-108.2(E) and 63.2-1900) — Insert costs for “health care coverage” when actually paid by a parent or that parent’s spouse, to the extent such costs are directly allocable to the child or children, and which are the extra costs of covering the child or children beyond whatever coverage the parent or that parent’s spouse providing the coverage would otherwise have. “Health care coverage” means any plan providing hospital, medical or surgical care coverage for dependent children provided such coverage is available and can be obtained by a parent, parents, or a parent’s spouse at a reasonable cost (defined as “available, in an amount not to exceed 5% of the parents’ combined income, and accessible through employers, unions or other groups or Department-sponsored health care coverage, without regard to service delivery mechanism”). This item should also include the cost of any dental care coverage for the child or children paid by a parent or that parent’s spouse. Lines 23 and 28 (Virginia Code § 20-108.2(F)) — Any child-care costs incurred on behalf of the child or children due to employment of the custodial parent shall be added to the basic child support obligation. Child-care costs shall not exceed the amount required to provide quality care from a licensed source. Line 32 — If Line (25) is larger than Line (30), check Mother on Line (32). If Line (25) is smaller than Line (30), check Father on Line (32). Lines 33 and 34 — If amounts paid to or for the child who is the subject of the order and derived by the child from the parent’s entitlement to disability insurance benefits have been included in a parent’s gross income, that amount should be subtracted from that parent’s child support obligation. Line 38 — If Line (35) is larger than Line (36), check Mother on Line (38). If Line (35) is smaller than Line (36), check Father on Line (38). Lines 39 and 40 — If Lines (31) and (37) are owed to the same party, put the sum of the amounts in these lines on Line (39) and, in Line (40), check the party checked on line (32). If Lines (31) and (37) are owed to different parties, put the difference between the amounts in these lines on Line (39) and, in Line (40), check the party to whom the larger of the amounts in Lines (31) and (37) are owed.

FEDERAL POVERTY GUIDELINES (Notice Date: January 24, 2013)

Household Size 1 2 3 4 5 6 7 8

Guideline plus 50% $ 17,505 $ 23,595 $ 29,685 $ 35,775 $ 41,865 $ 47,955 $ 54,045 $ 60,135

(Add $6,090 for each additional member in households of more than eight.)


Form DC-641 PARENTAGE SUPPLEMENT TO PETITION Form DC-641


Using This Form

1. Copies – same number as the number of copies of the petition to which this form is attached.

2. Prepared by person who prepares petition to which this form is attached.

3. Attachments

a. DC-511, PETITION (JUVENILE)

b. DC-610, PETITION FOR SUPPORT (CIVIL)

c. DC-612, DESERTION/NON-SUPPORT PETITION (CRIMINAL)


a. In Data Element No. 1, include Division of Child Support Enforcement (DCSE) I.D. number if DCSE is involved in case.

b. Include first name, middle names, last name, suffixes (Sr., Jr., etc.) and nicknames to the extent that they are known.

c. This information is needed because Va. Code § 20-49.8 requires its inclusion in any order determining parentage.

d. This form is used whenever parentage is an element of the case when either

˗ The parents of the child are not married and parentage has not been previously determined judicially, or

˗ The parents are married and parentage is disputed.


PARENTAGE SUPPLEMENT TO PETITION Case No. ...................................................................................... Commonwealth of Virginia Va. Code §§ 20-49.8 1. ............................................................................................................................................ , FULL NAME

who is ............................................. and was born on .......................................................... in ......................................................................................... RACE OR COLOR DATE STATE OR FOREIGN COUNTRY

is the father of the following children: Full Name Sex Birth Place Date of Birth

a. ............................................................................................................................................................................................................................................ b. ............................................................................................................................................................................................................................................ c. ............................................................................................................................................................................................................................................ d. ............................................................................................................................................................................................................................................

2. ............................................................................................................................................ , FULL NAME

is the mother of the above-listed children, and her maiden name is: .............................................................................................................. 3. ...............................................................................................................................................................................................................................................................

...............................................................................................................................................................................................................................................................

is the name and address of an informant who can furnish the information necessary to complete a new birth record.

[ ] I ask the court to join the above-named children as parties to the proceedings by serving the person having custody of

the children. I also ask the Court to appoint a guardian ad litem to represent the best interests of these children. I ask the Court to determine the parentage of the above-named children as claimed above. This supplement is incorporated into the PETITION to which the supplement is attached.

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Form DC-641 PARENTAGE SUPPLEMENT TO PETITION Form DC-641


Data Elements

1. Court case number. If Division of Child Support Enforcement (DCSE) is involved in the case, add the DCSE I.D. number under the court case number line.

2. Complete name of alleged father. See Using This Form, 4.b.

3. Race or color of alleged father.

4. Date of birth of alleged father.

5. Place of birth of alleged father.

6. Descriptive data of children whose parentage is in dispute.

7. Complete name of alleged mother. See Using This Form, 4.b.

8. Complete maiden name of alleged mother. See Using This Form, 4.b.

9. Name and mailing address of person who can give additional information to complete a new birth record. See Using This Form, 4.e.

10. Check this box if applicable.

Form DC-644 ORDER DETERMINING PARENTAGE Form DC-644


Using This Form

1. Copies

a. Original – to court. See Using This Form, 4(a). b. First copy – to Department of Vital Records. This copy must be certified.

c. Additional copies to each party in the case and, if copy is sent to Division of

Child Support Enforcement (DCSE), to DCSE.



a. If DCSE is involved in case, add DCSE I.D. b. Data Element Nos. 3, 4 and 5 should conform to the style of the case as shown on

the petition.

c. Include first name, middle name, last name, suffixes (i.e. Sr., Jr., etc.) and nicknames. It should have been alleged in district court form DC-641, PARENTAGE SUPPLEMENT TO PARENTAGE TO PETITION.

d. This information is required to be in all parentage orders pursuant to Va. Code

§ 20-49.8. It may be alleged in district court form DC-641, PARENTAGE SUPPLEMENT TO PETITION.

e. This order should be entered whenever parentage is at issue in a case and when

either

• the parents of the child are not married and parentage has not been judicially determined, or

• the parents are married and parentage is disputed.

f. If Data Element No. 18 is checked and a support order is to be entered in

connection with this order, then include the reimbursement costs in such order of support rather than in Data Element No. 19 of this order.

g. The reverse side of this form need only be completed on the Department of Vital

Records copy.

FORM DC-644 FRONT 10/11

ORDER DETERMINING PARENTAGE Case No. ............................................................................................ Commonwealth of Virginia Va. Code §§ 20-49.5, 20-49.8

[ ] Circuit Court ............................................................................................................................................................. [ ] Juvenile and Domestic Relations District Court ............................................................................................................................ v./In re ...............................................................................................................................

Present: [ ] Putative father [ ] Putative father's attorney ................................................................. [ ] Other .................................................................

[ ] Mother [ ] Mother's attorney .............................................................................................. [ ] Other .................................................................

Upon hearing the evidence, the Court finds that: 1. ........................................................................................................................... , FULL NAME (First, Middle, Last)

who is .............................................. and was born on ................................................ in .............................................................................................................. RACE DATE STATE OR FOREIGN COUNTRY

[ ] a. is the father of the following children: Full Name (First, Middle, Last) Sex Birth Place Date of Birth

(1) ..................................................................................................................................................................................................................................................

(2) ..................................................................................................................................................................................................................................................

(3) ..................................................................................................................................................................................................................................................

(4) ..................................................................................................................................................................................................................................................

[ ] b. is not the father of the following children: Full Name (First, Middle, Last) Sex Birth Place Date of Birth

(1) .................................................................................................................................................................................................................................................

(2) ..................................................................................................................................................................................................................................................

(3) ..................................................................................................................................................................................................................................................

(4) .................................................................................................................................................................................................................................................. 2. . ............................................................................................................................ , FULL NAME

is the mother of the above-listed children, and her maiden name is: ................................................................................................................................

3. [ ] yes [ ] no The children were made parties to the proceeding.

4. [ ] yes [ ] no The children were represented by a guardian ad litem or counsel. 5. ..................................................................................................................................................................................................................................................................... is the name and address of an informant who can furnish the information necessary to complete a new birth record.

(Complete the following if applicable) 6. [ ] The Court finds that the Virginia Department of Social Services is entitled to reimbursement for attorney’s fees and other costs from the father.

7. [ ] There being no other order providing for reimbursement by the father, the Court orders the father to pay to the Virginia

Department of Social Services the sum of $ .........................................................................

8. [ ] The father voluntarily testified under oath or affirmation that he is the father of a child whose parents are not married (or are not married to each other).

[ ] The court also required him to complete an acknowledgment of paternity on a form provided by the Department of Social Services pursuant to Va. Code § 20-49.5.

..................................................................... _____________________________________________________________ DATE JUDGE

Clerk’s Office: The Office of Vital Records cannot process this order without the highlighted information and the reverse completed. [ ] VITAL RECORDS [ ] DCSE [ ] PETITIONER [ ] RESPONDENT [ ] OTHER

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Data Elements, front 1. Court case number. If division of Child

Support Enforcement (DCSE) is involved, add DCSE I.D. number

2. Court jurisdiction.

3. Name of Petitioner or the Commonwealth. See Using This Form, 4(b).

4. Cross out the part of the case style that is inapplicable. See Using This Form, 4(b).

5. Name of respondent or the subject of the petition. See Using This Form, 4(b).

6. Check applicable box(es) and insert name(s) if appropriate.

7. Complete name of alleged father. See Using This Form, 4(c).

8. Race of alleged father.

9. Date of birth of alleged father.

10. Place of birth of alleged father.

11. Check this box if any of the children were found to be children of the alleged father and provide descriptive data for each child for whom the alleged father was found to be the father.

12. Check this box if any of the children were found not to be children of the alleged father and provide descriptive data for each child for whom the alleged father was found not to be the father.

13. Complete name of mother. See Using This Form, 4(c).

14. Complete maiden name of mother. See Using This Form, 4(c).

15. Check the applicable block.

16. Check the applicable block.

17. Name and mailing address of person who can give additional information to complete a new birth record. See Using This Form, 4(d).


19. If Data Element No. 18 is checked and no other order provides for reimbursement, check this box and insert the amount awarded. See Using This Form, 4(f).


21. If Data Element No. 20 is checked, check this box if the court required the father to complete an acknowledgement of paternity on a form provided by the Department of Social Services.



24. Check the applicable box to indicate to whom the copy should be provided.

FORM DC-644 REVERSE 02/04

ORDER DETERMINING PARENTAGE IMPORTANT BIRTH CERTIFICATE INFORMATION FOR PARENT/LEGAL GUARDIAN Contact the Office of Vital Records for information on how to obtain a copy of the birth certificate including the amount of any fee required. OFFICE OF VITAL RECORDS P.O. Box 1000 Richmond, VA 23218-1000 (804) 662-6200

FOR COURT USE ONLY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Circuit Court [ ] Juvenile and Domestic Relations District Court

I, the undersigned clerk or deputy clerk of the above-named court, authenticate pursuant to Va. Code § 8.01-391 (C) on this date that the document to which this authentication is affixed is a true copy of a record in the above-named court, made in the performance of my official duties. _____________________________ ________________________________________________ DATE CLERK/DEPUTY CLERK

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Data Elements, reverse

1. Insert the court name and check appropriate box. 2. Date of certification.

3. Signature of clerk or deputy clerk certifying that this is an authentic copy.

Form DC-645 INCOME DEDUCTION ORDER FOR SUPPORT Page: 1 EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT

DISTRICT COURT FORMS MANUAL JULY 2008

Using This Form

1. Copies (see Using This Form, 4.c.) a. Original (DC-645(A), INCOME DEDUCTION ORDER OF SUPPORT, page 1) – to court. b. Copy (DC-645(A), INCOME DEDUCTION ORDER OF SUPPORT, page 1) – to petitioner by mail. c. Copy (DC-645(A), INCOME DEDUCTION ORDER OF SUPPORT, page 1) – to employer to give to employee. d. Original (DC-645(B), EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, page 2) – to court. e. Copy (DC-645(B), EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, page 2) – to employer. f. Original (DC-645 (B), EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, page 3) – to employer. g. Original (DC-645(B), EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, page 4) – to serving officer for service of process,

then to court.

2. Prepared by clerk and: DC-645(A), INCOME DEDUCTION ORDER OF SUPPORT – signed by judge. DC-645(B), EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT – signed by clerk.

3. Attachments a. DC-646, COMPLIANCE PROVISIONS – INCOME DEDUCTION ORDER, to every copy of both of the orders. b. Only to original of DC-645(A), INCOME DEDUCTION ORDER OF SUPPORT.

− DC-615, RESPONDENT’S REQUEST FOR INCOME DEDUCTION ORDER, if filed. − DC-617, MOTION AND NOTICE OF INCOME DEDUCTION ORDER FOR SUPPORT, if issued. − DC-645(B), EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT.

4. Preparation Details a. This form contains two separate orders. They were placed in the same set to save clerical preparation time since both orders are

frequently produced at the same time. b. As the two orders are very similar and are signed by different people (see Using This Form, no. 2), check that the orders DC-

645(A) (pg. 1 of 4) and DC-645(B) (pg. 2 of 4) are signed separately. c. Remember to attach a copy of DC-646, COMPLIANCE PROVISIONS – INCOME DEDUCTION ORDER, to all copies of the orders,

original or otherwise. d. Data Element No. 6 – Respondent’s social security number must be on both orders (Va. Code § 20-79.1). e. Data Element No. 9 – The maximum percentage deductible from “disposable income” must be included in each order and is

determined by Va. Code § 34-29(b1) based on: − whether any other dependants not covered by the order in the case are being supported by the respondent, and − whether total support payments are more than 12 months in arrears.

The percentages are: 50% - other dependants, no arrearages over 12 weeks 55% - other dependants, arrearages over 12 weeks 60% - no other dependants, no arrearages over 12 weeks 65% - no other dependants, arrearages over 12 weeks

This information should be obtained from DC-615, RESPONDENT’S REQUEST FOR INCOME DEDUCTION ORDER, or from DC-617, MOTION AND NOTICE OF PROPOSED INCOME DEDUCTION ORDER FOR SUPPORT. Otherwise, additional information should be obtained in court to make this selection.

f. Data Element No. 17 – The judge needs to determine whether priority will be given to applying the payroll deduction to support payments or to health care coverage if the total deductible amount is insufficient to fully pay both support payments and health care coverage.

g. Once an INCOME DEDUCTION ORDER FOR SUPPORT, DC-645(A), is entered, additional EMPLOYER’S INCOME DEDUCTION ORDERS FOR SUPPORT, DC-645(B) to new or additional employers may be prepared without preparing and signing the INCOME DEDUCTION ORDER FOR SUPPORT, DC-645(A), portion of the form. In such situations, Data Element Nos. 5 (address only), 6 (address only), 7, 10, and/or 11 can be changed by the clerk from new information with a new hearing and without entry of a new INCOME DEDUCTION ORDER OF SUPPORT, DC-645(A), (or its former version, DC-632) being issued.

h. Data Elements Nos. 10 and 11 – If the pay interval in the support order does not agree with the respondent’s current pay interval for the employer to whom the EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, DC-645(B) is directed, convert the payment for purposes of the EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT, DC-645(B) to the respondent’s current pay interval by using the Payroll Conversion Table in Chapter 7 of the J&DR DISTRICT COURT MANUAL.

i. Data Element No. 18 – The reporting form to be completed by the employer is provided by the Division of Child Support Enforcement and is to be attached to the copy of the EMPLOYER’S INCOME DEDUCTION ORDER OF SUPPORT, DC-645(B), to be left with the employer by the serving officer.

j. DC-645(B), SERVICE OF PROCESS copy (back) – Because corporate employers are served pursuant to Va. Code § 8.01-513 (service of process of garnishments on corporations), the service of process format on the back of DC-645(B) is somewhat different from the format usually used in civil service of process. Service may also be made by transmission of a copy of the order by electronic means. Virginia Code § 20-79.1.


INCOME DEDUCTION ORDER FOR SUPPORT Case No. ........................................................................................ Commonwealth of Virginia VA. CODE §§ 20-79.1 to 20-79.3 DCSE No. .....................................................................................

1

2 [ ] original order [ ] modified order [ ] Circuit Court

3

.............................................................................................................................. [ ] Juvenile and Domestic Relations District Court

4...............................................................................................................................................................................................................................................................................

ADDRESS OF COURT


.............................................................................................................................. v. ..............................................................................................................................

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6 PETITIONER/PAYEE RESPONDENT/OBLIGOR

.............................................................................................................................. .............................................................................................................................. ADDRESS ADDRESS

.............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................

SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER

Having given notice as required by law or notice having been waived and finding that an income deduction order for support payments should be ordered, it is ORDERED that pursuant to Va. Code § 20-79.1, the respondent’s employer shall deduct support payments from the respondent’s income during each pay period beginning with the next regular pay period of the obligor following service of the order on the employer, as follows:

TO: .....................................................................................................................EMPLOYER

.............................................................................................................................

ADDRESS .............................................................................................................................

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$ .................................................................................................. or [ ] 50% [ ] 55% [ ] 60% [ ] 65% of respondent’s disposable income, whichever is less (but see No. 2 in the attached COMPLIANCE PROVISIONS)

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Regular pay period interval of the respondent: [ ] weekly ................................................................................................................... [ ] bi-weekly .............................................................................................................. [ ] semi-monthly ....................................................................................................... regular pay dates

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[ ] monthly ................................................................................................................. [ ] ................................................................................................................................. OTHER PAY INTERVAL AND REGULAR PAY DATES

[ ] Check if health care coverage is to be provided to the person listed below if they are eligible for cover under the employer’s enrollment provisions A. [ ] Respondent [ ] Petitioner is the employee

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B. [ ] Persons to be covered if eligible are your employee and: 13

NAME STATUS 1. ................................................................................................................................... 2. ................................................................................................................................... 3. ................................................................................................................................... 4. ................................................................................................................................... 5. ................................................................................................................................... 6. ................................................................................................................................... If there are insufficient funds to pay both the support amount shown at top of the order and the health care premium within the percentage limits as shown at top of the order then priority in payment shall be given to:

16Dependent Child Spouse Former Spouse

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[ ] support amount shown at top of order [ ] health care premium [ ] The employer also is required to advise the Virginia Department of Social Services in which plan the children are enrolled or if the children are ineligible for any

plan through the employer by using the accompanying reporting form.

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Send payments to: Virginia Department of Social Services Division of Child Support Enrollment P.O. Box 570

18 It is mandated by statute that the employer provide a copy of this Order to the respondent. Richmond, Virginia 23218-0570

Make checks payable to the Treasurer of Virginia.

[ ] The employer may combine payment pursuant to this order with payments pursuant to other orders which are sent to the same place in one check in conformance with Compliance Provisions, 4.c., attached to this Order.

[ ] Do not combine payment pursuant to this order with payments to other orders unless the exemption in paragraph 4.b. in the attached COMPLIANCE PROVISIONS applies to you.

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The attached COMPLIANCE PROVISIONS are incorporated into this order by reference. It is further ORDERED that the clerk shall issue orders directed to all present and future employers of the respondent which shall contain the above information and which shall also contain the COMPLIANCE PROVISIONS addressed to the employer.

.......................................................................................... _______________________________________________________________________ 20 21 DATE JUDGE

FORM DC-645(A) (MASTER, PAGE ONE OF FOUR) 05/08



Data Elements, DC-645(A), page one

1. Court case number. 2. Division of Child Support Enforcement case

I.D. number. 3. Check whether this order is the first order to

the employer (original) or is a subsequent order modifying an earlier order (modified).

4. Court name. Insert name and address of

court’s jurisdiction and check the applicable type of court.

5. Petitioner’s name, address and social security

number. See Using This Form, 4.g. 6. Respondent’s name, address and social

security number. See Using This Form, 4.d. and g.

7. Name and address of employer. See Using

This Form, 4.g. 8. Maximum monetary amount to be deducted

from respondent’s disposable income. 9. Maximum percentage of respondent’s

disposable income, which may be deducted. See Using This Form, 4.e.

10. Check appropriate box to show scheduled pay

intervals. See Using This Form, 4.g. and h. 11. Pay dates (examples: “Each Friday,” “1st and

16th of each month,” “4th Monday of each month”). See Using This Form, 4.g. and h.

12. Check this box if health care coverage through the employer’s health care plan is ordered.

13. Check the applicable box to designate through

which party’s employer health care coverage is to be provided.

14. Check this box if data element no. 12 is

checked. 15. Name each person (except the employee) for

whom the employee has been ordered to provide health care coverage.

16. For each person named in Data. Element No.

15, check the applicable box to show the relation of such person to the employee.

17. Check the appropriate box to show how

payments are to be prioritized if the employee’s income is insufficient to cover both child support and health care coverage. See Using This Form, 4.f.

18. If the Division of Child Support Enforcement

is enforcing the support obligation, check this box. See Using This form, 4.i.

19. Check the appropriate block as to whether

payment pursuant to this order may be combined with other payments to the Division of Child Support Enforcement.

20. Date of signing of order. 21. Signature of judge.


EMPLOYER’S INCOME DEDUCTION ORDER FOR SUPPORT Case No. ........................................................................................ Commonwealth of Virginia VA. CODE §§ 20-79.1 to 20-79.3 DCSE No. .....................................................................................

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2 [ ] original order [ ] modified order [ ] Circuit Court

3 .............................................................................................................................. [ ] Juvenile and Domestic Relations District Court

4...............................................................................................................................................................................................................................................................................

ADDRESS OF COURT


.............................................................................................................................. v. ..............................................................................................................................

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6 PETITIONER/PAYEE RESPONDENT/OBLIGOR

.............................................................................................................................. .............................................................................................................................. ADDRESS ADDRESS

.............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................

SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER

Pursuant to Va. Code § 20-79.1, an order has been entered in the above-styled case requiring all of the respondent’s employers to deduct support payments from the respondent’s income during each pay period. You are ordered to deduct the following amount from the respondent’s income during each pay period beginning with the next regular pay period after this order is served on you. You must send payment on the employee’s (respondent’s) payday.

TO: .....................................................................................................................EMPLOYER

.............................................................................................................................

ADDRESS .............................................................................................................................

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$ .................................................................................................. or [ ] 50% [ ] 55% [ ] 60% [ ] 65% of respondent’s disposable income, whichever is less

8 (but see No. 2 in the attached COMPLIANCE PROVISIONS) Regular pay period interval of the respondent: [ ] weekly ................................................................................................................... [ ] bi-weekly .............................................................................................................. [ ] semi-monthly ....................................................................................................... regular pay dates

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10 [ ] monthly ................................................................................................................. [ ] ................................................................................................................................. OTHER PAY INTERVAL AND REGULAR PAY DATES

[ ] Check if health care coverage is to be provided to the person listed below if they are eligible for cover under the employer’s enrollment provisions

A. [ ] Respondent [ ] Petitioner is the employee 12

B. [ ] Persons to be covered if eligible are your employee and:

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NAME STATUS 1. ................................................................................................................................... 2. ................................................................................................................................... 3. ................................................................................................................................... 4. ................................................................................................................................... 5. ................................................................................................................................... 6. ...................................................................................................................................

Dependent Child Spouse Former Spouse

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If there are insufficient funds to pay both the support amount shown at top of the order and the health care premium within the percentage limits as shown at top of the order then priority in payment shall be given to: [ ] support amount shown at top of order [ ] health care premium

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[ ] The employer also is required to advise the Virginia Department of Social Services in which plan the children are enrolled or if the children are ineligible for any plan through the employer by using the accompanying reporting form.

Send payments to: Virginia Department of Social Services Division of Child Support Enrollment P.O. Box 570

18 It is mandated by statute that the employer provide a copy of this Order to the respondent. Richmond, Virginia 23218-0570

Make checks payable to the Treasurer of Virginia. [ ] The employer may combine payment pursuant to this order with payments pursuant to other orders which are sent to the same place in one check in conformance

with Compliance Provisions, 4.c., attached to this Order. [ ] Do not combine payment pursuant to this order with payments to other orders unless the exemption in paragraph 4.b. in the attached COMPLIANCE

PROVISIONS applies to you.

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The attached COMPLIANCE PROVISIONS are incorporated into this order by reference. It is further ORDERED that the clerk shall issue orders directed to all present and future employers of the respondent which shall contain the above information and which shall also contain the COMPLIANCE PROVISIONS addressed to the employer.

.......................................................................................... _______________________________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK

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FORM DC-645(B) (MASTER, PAGE TWO OF FOUR) 05/08



Data Elements, DC-645(B), page two 1. Court case number.

2. Division of Child Support Enforcement case

I.D. number.

3. Check whether this order is the first order to the employer (original) or is a subsequent order modifying an earlier order (modified).

4. Court name and address. Insert name and address of court’s jurisdiction and check the applicable type of court.

5. Petitioner’s name, address and social security number. See Using This Form, 4.g.

6. Respondent’s name, residential address and social security number. See Using This Form, 4.d. and g.

7. Name and address of employer. See Using This Form, 4.g.

8. Maximum monetary amount to be deducted from respondent’s disposable income.

9. Maximum percentage of respondent’s disposable income, which may be deducted. See Using This Form, 4.e.

10. Check appropriate box to show scheduled pay intervals. See Using This Form, 4.g. and h.

11. Pay dates (examples: “Each Friday,” “1st and 16th of each month,” “4th Monday of each month”). See Using This Form, 4.g. and h.

12. Check this box if health care coverage through the employer’s health care plan is ordered.

13. Check the applicable box to designate through which party’s employer health care coverage is to be provided.

14. Check this box if data element no. 12 is checked.

15. Name each person (except the employee) for whom the employee has been ordered to provide health care coverage.

16. For each person named in Data. Element No. 15, check the applicable box to show the relation of such person to the employee.

17. Check the appropriate box to show how payments are to be prioritized if the employee’s income is insufficient to cover both child support and health care coverage. See Using This Form, 4.f.

18. If the Division of Child Support Enforcement is enforcing the support obligation, check this box. See Using This form, 4.i.

19. Check the appropriate block as to whether payment pursuant to this order may be combined with other payments to the Division of Child Support Enforcement.

20. Date of signing of order.

21. Signature of clerk or deputy clerk. Check the applicable status box.


Returns: Each person was served according to law, as indicated below, unless not found.


......................................................................................................................

EMPLOYER NAME ......................................................................................................................

Address ........................................................................................................ ......................................................................................................................

[ ] PERSONAL SERVICE Tel. No. .....................................................

.............................................................................................................................EMPLOYER NAME ............................................................................................................................. Address ............................................................................................................... ............................................................................................................................. .............................................................................................................................TEL. NO. FACSIMILE NO. I certify that on ........................................... DATE I sent to the named employer by electronic means a certified copy of this order. ____________________________________________ [ ] CLERK [ ] D TY CLERK

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Being unable to make personal service, a copy was delivered in the following manner: [ ] Served on registered agent of the corporation. List name and title:

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...................................................................................................................... [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above.

......................................................................................................................

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[ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.)

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[

] Served on the Clerk of the State Corporation Commission.

[ ] Not found ________________________________ SERVING OFFICER ...................................... for ___________________________________

DATE

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a. THIS ORDER IS BINDING UPON YOU AND YOUR EMPLOYEE: (i) UNTIL you receive a subsequent (more recently dated) court order affecting the petitioner and respondent listing on the

front of this Order; or, (ii) UNLESS, within five (5) business days from the service of this Order on you, you have either deposited by mail or

otherwise filed a written reply stating which of the requirements listed in b (below) has not been satisfied, after which this Order is void unless the court finds that such a reply is materially false. (Use this form by completing the portion below and either mailing or returning it to this court.) The clerk may issue a new order with corrected information, with which you must comply.

Call the clerk of this court if you have any questions concerning this Order. b. To the clerk of the court: This order is defective because it [ ] does not contain respondent’s correct social security number. [ ] does not contain a single monetary amount to be deducted for each regular pay period. [ ] does not contain the maximum percentage of disposable income (50%, 55%, 60%, 65%) which may be deducted for each regular

pay period.

12[ ] requires that payment be made other than by combined single payment and the exemption in paragraph 4.b. of the compliance

provisions applies to this employer and the order is not from a support agency outside this Commonwealth. [ ] requires that payment be made to someone or some organization other than the Virginia Department of Social Services. [ ] contains information which is in conflict with our current pay records (including regular pay intervals and regular pay dates) – the

correct information is:

...................................................................................................................................................................................................................................................................... ..................................................... _____________________________________________ by ______________________________________________ DATE EMPLOYER NAME SIGNATURE

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15 FORM DC-645(B) (MASTER, PAGE FOUR OF FOUR) 05/08


a. THIS ORDER IS BINDING UPON YOU AND YOUR EMPLOYEE: (i) UNTIL you receive a subsequent (more recently dated) court order affecting the petitioner and respondent listed on the

front of this Order; or, (ii) UNLESS, within five (5) business days from the service of this Order on you, you have either deposited by mail or

otherwise filed a written reply stating which of the requirements listed in b (below) have not be satisfied, after which this Order is void unless the court finds that such a reply is materially false. (Use this form by completing the portion below and either mailing or returning it to court.) The clerk may issue a new order with corrected information, with which you must comply.

Call the clerk of this court if you have any questions concerning this Order. b. To the clerk of the court: This order is defective because it

[ ] does not contain respondent’s correct social security number. [ ] does not contain a single monetary amount to be deducted for each regular pay period. [ ] does not contain the maximum percentage of disposable income (50%, 55%, 60%, 65%) which may be deducted for

each regular pay period.

12 [ ] requires that payment be made other than by combined single payment and the exemption in paragraph 4.b. of the

compliance provisions applies to this employer and the other is not from a support agency outside this Commonwealth. [ ] requires that payment be made to someone or some organization other than the Virginia Department of Social Services. [ ] contains information which is in conflict with our current pay records (including regular pay intervals and regular pay

dates) – the correct information is: ....................................................................................................................................................................................................................................................


............................................ ................................................................................................ by _____________________________________________________ 13 14 15

DATE EMPLOYER NAME SIGNATURE FORM DC-645(B) (MASTER, PAGE THREE OF FOUR) 05/08



Data Elements, DC-645(B), pages three and four

1. Name and address (and telephone number if

known) of employer (to be inserted by clerk or judge).

2. Serving officer to check this box if personal

service obtained.

3. Serving officer to check the appropriate box to designate type of substitute service.

4. If served on registered agent of a

corporation, check the box and insert name and title of such person.

5. If served by leaving a copy with a family

member age 16 or older, check appropriate box and insert required information.

6. Check if served by posting.

7. Check if served on clerk of State

Corporation Commission.



10. Date of service. 11. Name of sheriff if served by deputy sheriff. Employer copy: 12. Employer seeking to void order checks the

appropriate box(es) and, if applicable, completes the correct pay record information.

13. Date of signing by employer or employer’s

authorized employee. 14. Name of employer. 15. Name of employer’s authorized employee. 16. Name of employer. 17. Address of employer. 18. Telephone and facsimile number of employer. 19. Date of electronic transmission of order. 20. Signature of clerk. Check applicable box.

Form DC-646 COMPLIANCE PROVISIONS – Page: 1 INCOME WITHHOLDING FOR SUPPORT


Using This Form

1. Copies – see attachments. 2. No preparation needed. 3. Attachments (every copy of these orders).

a. District court form DC-645, INCOME WITHHOLDING FOR SUPPORT

4. Preparation details – none.



COMPLIANCE PROVISIONS — INCOME WITHHOLDING FOR SUPPORT

To the Employer: By law, in complying with this Order,

1. You must provide the employee/obligor with a copy of this Order.

2. You must obey this Order before you comply with any other lien against (deduction from) respondent’s disposable income created by state law, such as a garnishment or attachment summons. “Disposable Income” is that income left after deductions required by law are made.

Exceptions: a. If you have been served previously with an order for income deductions for support from any court or an

administrative agency, including the Virginia Department of Social Services, Division of Child Support Enforcement, you must prorate among the orders based upon the current amounts due, with any remaining income prorated among the orders for accrued arrearages, if any, and

b. The maximum amount of employee/obligor’s disposable income which may be deducted for support payments on this order is the percentage shown on the order. If health insurance coverage is also ordered, the order shall specify either support withholdings or insurance premium deductions as having priority for the duration of the order in the event the maximum total deduction permitted at any time by § 34-29 is insufficient to cover both; the employer shall consider and direct insurance premium deductions and support withholdings the same for purposes of applying § 34-29.

3. If required by the support order, you are ordered to:

a. Enroll the persons described above in a group health insurance plan or other similar plan providing health care services or coverage offered by the employer, without regard to enrollment season restrictions, if such persons are eligible for such coverage under the employer’s enrollment provisions, and

b. Deduct any required premium from the employee’s income to pay for the insurance.

If more than one plan is offered by the employer, the persons named in the order shall be enrolled prospectively in the insurance plan in which the employee is enrolled or, if the employee is not enrolled, in the least costly plan otherwise available. The employer shall also enroll the children of an employee in the appropriate health coverage plan upon application by the children’s other parent or legal guardian or upon application by the Department of Medical Assistance Services. The employer shall not be obligated to subsequently make or change such enrollment if the group health insurance plan or other factors change after the spouse’s, former spouse’s or child’s initial eligibility for coverage is initially determined in response to the order for withholding. However, the employer shall not disenroll such children unless the employer (i) is provided satisfactory written evidence that such court or administrative order is no longer in effect, (ii) is provided satisfactory written evidence that the children are or will be enrolled in a comparable health coverage plan which will take effect not later than the effective date of such disenrollment, or (iii) has eliminated family health coverage for all of its employees. In each case enforced by the Virginia Department of Social Services, the employer shall advise the Department in which plan the children are enrolled or if the children are ineligible for any plan through the employer. A one-time fee of not more than five dollars may be charged by the employer to the employee for the administration of this requirement.

4. a. You must deduct and forward all payments on employee/obligor’s regular pay date or reply that no funds were deductible, and

b. You may comply by sending payment to the Division of Child Support Enforcement (“DCSE”) of the Virginia Department of Social Services. As directed in the order, payment may be sent in a check made payable to the Treasurer of Virginia by first class mail or by submitting such amounts by electronic funds transfer transmitted within four days of the employee/obligor’s regular pay date together with employee/obligor’s name, employee/obligor’s social security number, and the DCSE number, if any, at the top of the order. All employers with at least 100 employees and all payroll processing firms with at least 50 clients shall remit payments by electronic funds transfer. (Contact the Division of Child Support Enforcement at 1-800-257-9986, to arrange electronic funds transfer.) However,

— an employer of 10,000 persons or more shall not be required to make payments to DCSE other than by combined single payments to the Division’s central office in Richmond without the express written consent of the employer unless the order is from a support agency outside the Commonwealth, and

c. If deductions are taken from more than one employee, they may be combined into a single check if accompanied by a list showing for each order: (1) employee/obligor’s name, (2) employee/obligor’s social security number, (3) the DCSE number (if none, then Case number) at the top of the order, (4) the amount deducted pursuant to each order or a statement that no income was deductible, and (5) the date that payment was withheld from the employee/obligor’s income.




5. In addition to the payment amount described on the front, you may (but are not required to) also deduct for yourself from the employee/obligor’s earnings a fee of five dollars for each deduction for support or for a reply that no funds were deductible to cover your costs of administering this income deduction order; however, this fee shall not be deducted if the child support withholding amount is being collected from unemployment insurance benefits.

6. If you receive an order which

— does not contain employee/obligor’s correct social security number, does not specify a single monetary amount to be deducted for each pay period of the respondent/obligor, or does not state the maximum percentage of disposable income which may be deducted for each regular pay period of the respondent/obligor, or — contains information which is in conflict with your current pay records (including regular pay intervals and regular pay dates), or — requires that payment be made other than by combined single payment without the express written consent of the employer, and the exemption in paragraph 4.b. (above) applies to you, or — requires that payment be made to someone other than the Division of Child Support Enforcement of the Virginia Department of Social Services, or its designee,

then you may deposit in the mail or otherwise file a reply within five (5) business days from service of this order stating which of the above requirements have not been satisfied, after which this order is void unless the court finds that such reply is materially false. The clerk may issue a new order with the corrected information with which you must comply.

7. You and the employee/obligor must notify the Department of Child Support Enforcement of the Virginia Department of Social Services when employment terminates and give the employee/obligor’s last known address and the name and address of the new employer, if known.

8. The employee/obligor’s rights are protected pursuant to Virginia Code § 63.2-1944. No employer shall

discharge any employee, take disciplinary action against an employee or refuse to employ a person because of this order.

IF YOU FIRE, REFUSE TO HIRE OR TAKE DISCIPLINARY ACTION AGAINST AN EMPLOYEE BECAUSE OF THIS ORDER, YOU ARE LIABLE FOR A CIVIL FINE OF UP TO $1,000.00.

9. IF YOU FAIL TO WITHHOLD OR SEND PAYMENTS IN THE MANNER DESCRIBED IN THIS

ORDER, YOU ARE LIABLE FOR ANY AMOUNT NOT WITHHELD OR SENT IN A TIMELY MANNER.

10. THIS ORDER IS BINDING UPON YOU AND YOUR EMPLOYEE. YOU MUST COMPLY WITH

THIS ORDER UNTIL YOU RECEIVE A SUBSEQUENT (MORE RECENTLY DATED) COURT ORDER AFFECTING THE PARTIES LISTED ON FIRST PAGE OF THE ORDER.

Call the clerk of this court if you have any questions concerning this order. FORM DC-646 (MASTER, PAGE TWO OF TWO) 11/10

Form DC-650 PROTECTIVE ORDER – Form DC-650 FAMILY ABUSE


Using This Form

1. Copies


c. Attested copy – to petitioner.


4. Preparation details –

a. The address and telephone number of the allegedly abused person should not be

entered in the service box on page 3 of this form. This information is to be kept confidential. District court form DC-621, NONDISCLOSURE ADDENDUM, should be used to collect this information.

b. The TEMPORARY SUPPORT ORDER, page 4 of this order, should be used only when

the court is ordering temporary support for the children of petition and respondent in conjunction with a protective order. Petitioner should be required to file a petition for support so that a full evaluation of support under the applicable statutes can be made.

FORM DC-650 (MASTER, PAGE ONE OF ______) 07/11


MO. DAY YR. FT. IN.

SSN


PROTECTIVE ORDER – FAMILY ABUSE Case No. .......................................................................... Commonwealth of Virginia VA. CODE § 16.1-279.1 [ ] Circuit Court ............................................................................................................................................ [ ] Juvenile and Domestic Relations District Court

[ ] Amended Protective Order [ ] Extension of Protective Order [ ] Conviction for Violation of Protective Order

PETITIONER PETITIONER’S DATE OF BIRTH

LAST FIRST MIDDLE

And on behalf of minor family or household members: Other protected family or household members: (list each name and date of birth) (list each name and date of birth) ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................

V.


LAST FIRST MIDDLE

Petitioner’s relationship to Respondent: ................................................................................................................................ ................................................................................................................................ RESPONDENT’S ADDRESS

................................................................................................................................ Distinguishing features: ........................................................................... ................................................................................................................................

THE COURT FINDS that it has jurisdiction over the parties and subject matter, that the Respondent was given reasonable notice and an opportunity to be heard, AND that the Petitioner has proven the allegation of family abuse by a preponderance of the evidence, a motion to modify or extend a protective order was properly before the court, or the Respondent has been convicted of a violation of a protective order pursuant to Va. Code § 16.1-253.2. Accordingly, to protect the health and safety of the Petitioner and family or household members of the Petitioner, THE COURT ORDERS that: [ ] The Respondent shall not commit acts of family abuse or criminal offenses that result in injury to person or property. [ ] The Respondent shall have no contact of any kind with the Petitioner


[ ] The Respondent shall have no contact of any kind with the family or household members of the Petitioner named above [ ] except as follows: ...................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................ [ ] Additional terms of this order are set forth on page two.

THIS ORDER SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL

WARNINGS TO RESPONDENT: (See additional warnings to Respondent on page two.) Full Faith and Credit: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, and any U.S. Territory, and may be enforced on Tribal Lands (18 U.S.C. § 2265). Federal Offenses: Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. § 2262). Federal law provides penalties for possessing, transporting, shipping, receiving or purchasing any firearm or ammunition while subject to a qualifying protective order and under the circumstances specified in 18 U.S.C. § 922(g)(8). Only the court can change this order.


................................................................... at 11:59 p.m. MONTH DAY YEAR

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1. Court case number. 2. Name and type of court.

3. Check box to indicate if amended

protective order.

4. Check box to indicate extension of existing protective order.

5. Check box to indicate if issued as a

result of a conviction for violation of existing protective order.


7. Petitioner’s date of birth.

8. List the name(s) and date(s) of birth

of any minor family members or household members who will be covered by the protective order.

9. List the name(s) and date(s) of birth

of each other family or household member who will covered by the protective order.

10. Respondent’s name.

11. Insert petitioner’s relationship to

respondent (spouse, former spouse, etc.).

12. Respondent’s address.

13. Insert identifying information for

respondent, if known.

14. List other distinguishing features of respondent not listed in Data Element No. 13.

15. Check box if a weapon has been involved in any of the previous altercations between the parties.

16. Check if ordered.


18. If applicable, check this box and

specify exceptions to condition that respondent have no contact with the petitioner.


20. If applicable, check this box and

specify exceptions to condition that respondent have not contact with the family or household members named in this order.

21. Check if additional terms of this

order are set forth on page 2.

22. Date on which this order expires.

23. Insert total number of pages of this order.

FORM DC-650 (MASTER, PAGE TWO OF ______) 07/14

Case No. .......................................................................... It is further ORDERED as follows: [ ] The Petitioner is granted possession of the residence occupied by the parties to the exclusion of the Respondent.

The residence is located at .................................................................................................................................................................................................. The Respondent shall immediately leave and stay away from the residence; however, no such grant of possession

shall affect title to any real or personal property. [ ] Until further order, being necessary for the protection of the Petitioner and family or household members of the

Petitioner, [ ] temporary custody of [ ] temporary visitation with .................................................................................................................................... is as follows: ..............................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................

[ ] The Respondent shall not terminate [ ] Respondent shall restore necessary utility service(s) to the premises

indicated above, specifically, ............................................................................................................................................................................................ UTILITY SERVICE(S)

[ ] The Petitioner is granted temporary exclusive possession or use of a motor vehicle jointly owned by the parties or

owned by the Petitioner alone, described as follows: ..........................................................................................................................................

..................................................................................................................................................... Such grant shall not affect title to the vehicle. [ ] The Respondent shall not terminate the [ ] insurance [ ] registration [ ] taxes on this motor vehicle. [ ] The Respondent shall maintain the [ ] insurance [ ] registration [ ] taxes for this motor vehicle.

[ ] The Respondent shall provide suitable alternative housing for the Petitioner [ ] and family or household members

as follows: ................................................................................................................................................................................................................................... [ ] The Respondent shall pay deposit(s) to connect or restore necessary utility service(s) in the alternative housing,

specifically, ................................................................................................................................................................................................................................. UTILITY SERVICE(S)

[ ] The Respondent shall participate in the following treatment, counseling or other program: .........................................................

............................................................................................................................................................................................................................................................ PROGRAM NAME AND ADDRESS

[ ] The Petitioner is granted possession of the companion animal described as .......................................................................................... NAME/TYPE

[ ] It is further ordered that .......................................................................................................................................................................................................

............................................................................................................................................................................................................................................................

[ ] Supplemental Sheet to Protective Order, Form DC-653, attached and incorporated by reference. Number of supplemental pages ...........................

[ ] Final judgment having been rendered on appeal from the juvenile and domestic relations district court, this matter is remanded to the jurisdiction of the juvenile and domestic relations district court in accordance with Virginia Code § 16.1-297.

...................................................................... __________________________________________________________________ DATE JUDGE

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1. Court case number. 2. If petitioner is given exclusive possession of the residence occupied by the parties, check

this box. Insert the address of the residence.

3. Check if adjudicating temporary custody or visitation, check appropriate box(es) and describe terms of order concerning temporary custody or visitation.

4. Check appropriate box regarding utility services, if ordered.

5. Check if ordered and insert description of vehicle.

6. Check applicable boxes for vehicle listed in Data Element No. 5.

7. Check if applicable and insert names of persons for whom housing must be provided and

other orders relating to housing.

8. Check if payment of deposit(s) for utility service(s) for alternative housing is ordered and indicate specific utility service(s).

9. If applicable, check and complete provisions regarding treatment or programs.

10. Check box if possession of companion animal is granted. List name and type of

companion animal if applicable.

11. Insert any additional terms.

12. Check if a SUPPLEMENTAL SHEET TO PROTECTIVE ORDER, form DC-653, is attached and insert number of supplemental pages.

13. Check if this order is being issued by a circuit court on appeal and the matter is being

remanded to the juvenile and domestic relations district court upon conclusion of the appeal.

14. Date of entry.


16. Enter total number of pages of this order.

FORM DC-650 (MASTER, PAGE THREE OF ______) 07/14

Case No. ................................................................................... RETURNS: Each person was served according to law, as indicated below, unless not found.

RESPONDENT:

NAME .................................................................................................................................... .................................................................................................................................................... ADDRESS ............................................................................................................................ ....................................................................................................................................................


NAME ................................................................................................................................... ....................................................................................................................................................

[ ] PERSONAL SERVICE TELEPHONE NUMBER .................................................................


[ ] NOT FOUND [ ] NOT FOUND

__________________________________________________________

SERVING OFFICER

for _____________________________________________________ .................................................................................................................................................

DATE AND TIME

______________________________________

SERVING OFFICER

for _____________________________________________________ ..................................................................................................................................................

DATE AND TIME

RESPONDENT’S DESCRIPTION (for VCIN entry):

RACE ................................ SEX .......................................................................

DOB: .......................................................................................................................................

HGT .................................... WGT .....................................................................................

EYES ................................. HAIR ....................................................................................

SSN .........................................................................................................................................

Relationship to Petitioner/Plaintiff ............................................................................

Distinguishing features ...................................................................................................

....................................................................................................................................................


by ............................................................................................................................................. TITLE

.....................................................................................................................................................

SIGNATURE .....................................................................................................................................................

ADDITIONAL WARNINGS TO RESPONDENT: Pursuant to Code of Virginia § 18.2-308.1:4, Respondent shall not purchase or transport any firearm while this order is in effect. If Respondent has a concealed handgun permit, Respondent must immediately surrender that permit to the court issuing this order. If Respondent violates the conditions of this order, Respondent may be sentenced to jail and/or ordered to pay a fine. This order will be entered into the Virginia Criminal Information Network. Either party may at any time file a motion with the court requesting a hearing to dissolve or modify this order; however, this order remains in full force and effect unless and until dissolved or modified by the court. DEFINITIONS: “Family abuse” means any act involving violence, force, or threat that results in bodily injury or places one in reasonable apprehension of death, sexual assault, bodily injury and that is committed by a person against such person’s family or household member. Such act includes, but is not limited to, any forceful detention, stalking, criminal sexual assault in violation of Article 7 (§ 18.2-61 et. seq.) of Chapter 4 of Title 18.2, or any criminal offense that results in bodily injury or places one in reasonable apprehension of death, sexual assault, or bodily injury. “Family or household member” means (i) the person’s spouse, whether or not he or she resides in the same home with the person, (ii) the person’s former spouse, whether or not he or she resides in the same home with the person, (iii) the person’s parents, stepparents, children, stepchildren, brothers, sisters, half-brothers, half-sisters, grandparents and grandchildren regardless of whether such persons reside in the same home with the person, (iv) the person’s mother-in-law, father-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law who reside in the same home with the person, or (v) any individual who has a child in common with the defendant, whether or not the person and that individual have been married or have resided together at any time, or (vi) any individual who cohabits or who, within the previous twelve (12) months, cohabitated with the person, and any children of either of them residing in the same home with the person.

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2. Name and address (and telephone number if known) of party to be served (to be inserted

by clerk or judge).






8. Identifying information of respondent (for VCIN entry).

9. Insert petitioner’s name. Do not include petitioner’s address or telephone information in the service box.

10. If copy delivered to petitioner instead of being served, check box and insert the name of

the person to whom a copy of the order was given.

11. Insert the title of the individual giving a copy of the order to petitioner.

12. Signature of individual giving a copy of the order to the petitioner.


14. Enter total number of pages of this order.

FORM DC-650 (MASTER, PAGE FOUR OF ______) 11/10

TEMPORARY SUPPORT ORDER - Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PROTECTIVE ORDER – FAMILY ABUSE COMMONWEALTH OF VIRGINIA Va. Code § 16.1-279.1 A1

[ ] Circuit Court . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Juvenile and Domestic Relations District Court PETITIONER/PLAINTIFF: RESPONDENT: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LAST FIRST MIDDLE LAST FIRST MIDDLE

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE OF BIRTH OF PETITIONER RESPONDENT’S ADDRESS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The court finds that the following dependents: NAME SOC. SEC. # SEX DATE OF BIRTH RELATIONSHIP TO RESPONDENT (last 4 digits only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . are entitled to temporary support in conjunction with the issuance of a Protective Order—Family Abuse until an Order of Support can be issued in a support proceeding. Therefore, the court ORDERS Respondent to pay $ . . . . . . . . . . . . . . . . . . . . . . . . . per month for all children listed above payable $ . . . . . . . . . . . . . . . . . per . . . . . . . . . . . . . . . . . . . . . beginning on . . . . . . . . . . . . . . . . . . . . INTERVAL DATE to be paid as follows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . This temporary child support order will terminate once a separate order to pay child support has been entered pursuant to § 20-108.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _________________________________________________ DATE JUDGE

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Data Elements, page four

(complete only if support is ordered)

1. Court case number. 2. Court name. Check the appropriate box for the court in which the order is being issued.


4. Date of birth of petitioner.


6. Address of respondent.

7. Insert information for all children for whom support is ordered.

8. Insert the monthly amount due.

9. Insert the amount of each payment.

10. Time (week, month, etc.) for which each payment is due.

11. Date on which first payment is due.

12. Provide details of how the payment is to be delivered to petitioner to ensure the safety of

petitioner and the children.



15. Enter total number of pages.

Form DC-652 ORDER DISSOLVING PROTECTIVE ORDER Form DC-652


Using This Form

1. Copies


c. Attested copy – to petitioner.



a. This form is used to dissolve a protective order when requested by a party(ies).



MO. DAY YR. FT. IN.

SSN



MO. DAY YR. FT. IN.

SSN


ORDER DISSOLVING PROTECTIVE ORDER Case No. ........................................................................................................ COMMONWEALTH OF VIRGINIA Va. Code §§ 16.1-253, 16.1-253.1, 16.1-253.4, 16.1-277.02, 16.1-278.2, ........................................................................................................................... 16.1-278.3, 16.1-279.1, 19.2-152.8, 19.2-152.9, 19.2-152.10 HEARING DATE AND TIME

[ ] General District Court [ ] Circuit Court ............................................................................................................................................ [ ] Juvenile and Domestic Relations District Court In re: ............................................................................................................................................................................................................................................................

NAME OF CHILD

PETITIONER: PETITIONER’S DATE OF BIRTH

LAST FIRST MIDDLE

V.

RESPONDENT (No. 1): RESPONDENT (No. 1) IDENTIFIERS

........................................................................................................................... RESPONDENT (NO. 1) ADDRESS ...........................................................................................................................

RESPONDENT (No. 2): RESPONDENT (No. 2) IDENTIFIERS

........................................................................................................................... RESPONDENT (NO. 2) ADDRESS ...........................................................................................................................

A(n) [ ] EMERGENCY PROTECTIVE ORDER – FAMILY ABUSE, Form DC-626 [ ] PRELIMINARY PROTECTIVE ORDER – FAMILY ABUSE, Form DC-627 [ ] PROTECTIVE ORDER – FAMILY ABUSE, Form DC-650 [ ] EMERGENCY PROTECTIVE ORDER, Form DC-382 [ ] PRELIMINARY PROTECTIVE ORDER, Form DC-384 [ ] PROTECTIVE ORDER, Form DC-385 [ ] PRELIMINARY CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT, Form DC-527 [ ] CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT, Form DC-532 [ ] PRELIMINARY CHILD PROTECTIVE ORDER, Form DC-545 [ ] CHILD PROTECTIVE ORDER, Form DC-546

was issued by [ ] this Court [ ] ........................................................................................... Court [ ] a magistrate on ................................................... DATE

[ ] A motion requesting that the protective order be dissolved has been filed by the [ ] Petitioner [ ] Respondent

[ ] ...................................................................................................................................................................................................................................................... Based on the evidence presented at the hearing on this matter, the Court finds that sufficient reason exists for the dissolution of the protective order described above.

THEREFORE, THE PROTECTIVE ORDER ISSUED ON ........................................................... IS HEREBY ORDERED DISSOLVED. DATE

IF A TEMPORARY SUPPORT ORDER WAS ISSUED IN CONJUNCTION WITH A PROTECTIVE ORDER – FAMILY ABUSE, FORM DC-650, IT IS ALSO DISSOLVED. ....................................................................................... _____________________________________________________________ DATE JUDGE

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2. Hearing date and time.

3. Court name and type.

4. Name of child, if applicable.


6. Date of birth of petitioner.

7. Name of Respondent No. 1.

8. Address of Respondent No. 1.

9. Insert identifying information for Respondent No. 1.

10. Name of Respondent No. 2, if applicable.

11. Address of Respondent No. 2, if applicable.

12. Insert identifying information for Respondent No. 2, if applicable.

13. Check the appropriate box to indicate the type of protective order being dissolved.

14. Check the appropriate box to indicate whether the protective order was issued by the same court that is dissolving the protective order, a different court than indicated in Data Element No. 3, or a magistrate.

15. If issued by a different court than indicated in Data Element No. 3, insert name of

different court.

16. Indicate the date of issuance of the protective order.

17. Check the appropriate box to indicate who requested the dissolution of the protective order, and insert the name of the requesting party if it is someone other than the petitioner or the respondent.

18. Indicate the date of issuance of the protective order.

19. Date of issuance of this order.



Case No. ........................................................................................................ RETURNS: Each person was served according to law, as indicated below, unless not found.

RESPONDENT (No. 1): NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PETITIONER: (See form DC-621, NON-DISCLOSURE ADDENDUM) NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] PERSONAL SERVICE TELEPHONE NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


[ ] NOT FOUND [ ] NOT FOUND _________________________________________________________

SERVING OFFICER

for ___________________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DATE AND TIME

________________________________________________________

SERVING OFFICER

for ___________________________________ h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DATE AND TIME

[ ] Copy delivered to: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TITLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Copy delivered to: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TITLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RESPONDENT (No. 2): NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] PERSONAL SERVICE TELEPHONE NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] NOT FOUND

_________________________________________________________

SERVING OFFICER

for ____________________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DATE AND TIME

[ ] Copy delivered to: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TITLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2. Name and address (and telephone number, if known) of party to be served (to be inserted by clerk or judge).






8. Check this box if, instead of service of the order, the order is delivered to the party or

family or household member. Insert name of person to whom copy of the order is given.

9. Title of individual giving copy of order to petitioner.

10. Signature of individual giving copy of order to petitioner.

11. Name and address (and telephone number, if known) of second party to be served (to be inserted by clerk or judge).

12. Insert petitioner’s name. Do not include petitioner’s address or telephone information in

the service box.

Form DC-653 SUPPLEMENT SHEET TO PROTECTIVE ORDER Form DC-653

Using This Form

1. Copies

a. Original – to court. b. Additional copies should be distributed along with copies of the associated

protective order as dictated by court procedures.


a. When the court is ordering temporary support for the children of the petitioner and respondent in conjunction with a protective order, the form TEMPORARY SUPPORT ORDER (now page 3 of form DC-650, PROTECTIVE ORDER – FAMILY ABUSE) should be used, not form DC-653, SUPPLEMENTAL SHEET.


SUPPLEMENTAL SHEET TO Case No. ........................................................................................ 1

PROTECTIVE ORDER ............................................................................................................ 2

DATE OF HEARING ..................................................................................................................... v./In re: ............................................................................................................... 3

Present: [ ] Petitioner.......................................................................................... [ ] Petitioner’s Attorney .....................................................................

[ ] Respondent .................................................................................... [ ] Respondent’s Attorney ................................................................

[ ] Other................................................................................................... [ ] Other .......................................................................................................

4

Having ordered on the front or page one (1) of this order the attachment and incorporation of this supplemental sheet for additional orders of this Court, THE COURT FURTHER ORDERS THAT: .............................................................................................................................................................................................................................................................

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FORM DC-653 (MASTER, PAGE ______ OF ______) 10/08

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Form DC-653 SUPPLEMENT SHEET TO PROTECTIVE ORDER Form DC-653


Data Elements


3. Insert name of petitioner and respondent or other associated case caption.

4. Check appropriate box(es) and insert name(s) of the party(ies) present at the hearing.

5. Enter additional orders of the court.

6. Indicate page numbers.

Form DC-660 Form DC-660PERFORMANCE BOND


1. Copies (Contact the court to determine if you should bring copies to the Clerk's Office or ifcopies will be made upon filing.)

a. Original--to court with case papers.

b. First copy--to surety. If more than one surety, prepare additional copies.

c. Second copy--to principal on bond.

d. Additional copies as dictated by local practice.

2. Prepared by person appealing the case and acknowledged by clerk or judge.


PERFORMANCE BOND Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Va. Code §§ 16.1-278.16; 20-114

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CITY/COUNTY

[ ] Juvenile and Domestic Relations District Court[ ] Circuit Court

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v./ In re . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Order, Judgment or Decree

Type of performance to be secured by bond:

[ ] custody [ ] visitation [ ] support [ ] other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name(s) and address(es) of the principal(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name(s) and address(es) of the surety and, if executed by someone authorized to act for the surety, the name(s) and address(es) andtitle (attorney-in-fact, etc.) of such authorized person.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The undersigned each hereby acknowledge himself, his heirs, and his assigns indebted jointly and severally to

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the sum of $. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . that is secured by ash [OR] [ ] Surety (and if property is used to establish the solvency of the surety, the undersigned, having demonstrated the

n e of their interest in the property to the officer taking this bond, also make oath that the equity of the undersigned in the propertyequals or exceeds the amount of this bond). The undersigned each waives all benefit of the homestead exemptions as to the debt ofthis bond.

The condition of this debt shall be that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .shall perform all of the terms and conditions of an order, decree or judgment entered by this court, which is described above andwhich is incorporated by reference in this bond, and that such performance shall be made as prescribed in such order, decree orjudgment without variance from its terms. If this condition if faithfully filled, this debt is to be void; otherwise, it is to remain in fullforce and effect until satisfied, declared void, or released either by a court of competent jurisdiction or by a release executed by allpersons for whose benefit the bond is posted.

_ ________________________________________(seal) _ _______________________________________(seal) PRINCIPAL SURETY

______________________________________________(seal) ____________________________________________(seal) PRINCIPAL SURETY

____________________________________________(seal) SURETY

Commonwealth of ____ ______________________, [ ] City [ ] County of ___ ______________________________

Acknowledged, subscribed and sworn to/acknowledged before me this day by the above-named persons.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ ____________________________________________ DATE [ ] CLERK [ ] JUDGE [ ] NOTARY PUBLIC

My Commission Expires: . . . . . . . . . . . . . . . . . . . . . . . . . .

Court Use Only:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE RECEIVED RECEIPT NO (IF CASH DEPOSITED) DATE DISBURSED/DISCHARGED

Accepted by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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10 11

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1617

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20 21 22

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Form DC-660 Form DC-660PERFORMANCE BOND

Data Elements


2. Name of city or county in which the courtis located.

3. Check the type of court.

4. Name(s) of plaintiff(s)/petitioner(s).

5. Name(s) of defendant(s)/respondent(s).

6. Date of court order, judgment or decreerequiring the performance of the actionfor which this bond is being posted.

7. Check and, if applicable, describe the typeof action whose proper performance is tobe secured by this bond.

8. Name(s) and address(es) of each principalon the bond.

9. Name(s) and address(es) of each surety onthe bond or such surety's attorney-in-fact.

10. Name(s) of each person or entity forwhose benefit the bond is being posted. In other words, the person to whom thebond would be paid if the performance isnot done.

11. Amount of bond.

12. Check type of security pledged to securethe bond.

13. Name(s) of each person or entity whoseperformance is being secured by thisbond.

14. Signature of each principal on the bondnamed in Data Element No. 8.

15. Signature of each surety named in DataElement No. 9. If a corporate surety, theattorney-in-fact should sign the name ofthe corporation and also sign as theauthorized attorney-in-fact.

To be completed by person acknowledgingthe signature(s) of the principal(s) and/orsurety(ies)16. Name of state where acknowledgment is

taken.

17. Check the type of locality and insert thename of the locality where theacknowledgment is taken.

18. Date on which the acknowledgment istaken.

19. Signature of person taking theacknowledgment. Check the appropriatetitle box below the signature line. If takenby a notary, also include the expirationdate of the notary's commission.

For court use only20. Date bond received by court.

21. If bond secured by cash deposit, insertcourt receipt number.

22. Date bond is disbursed or discharged.

23. Signature and title of person acceptingbond for the court.

Form DC-670 PETITION FOR SUSPENSION OF PROFESSIONAL Page: 1 OR OTHER LICENSE


Using This Form

This petition is supplied by the clerk to an intake officer of the court service unit, an attorney, or the Division of Child Support Enforcement for use when petitioner seeks the court to order a suspension of an obligor's professional or recreational license because an obligor is delinquent in the payment of child support by a period of 90 days or more for $5,000 or more.

The original petition should be indexed and docketed as a new case, a court date set by the clerk for the court to hear the petition, and the case filed in the appropriate pending court date file. A copy of the petition should be attached to the DC-510 summons and served on the petitioner and the respondent/obligor. When the return of service is filed with the clerk, the return(s) should be attached to the petition in chronological order. It is a master form and copies must be made by photocopying.



PETITION FOR SUSPENSION OF PROFESSIONAL OR OTHER LICENSE Commonwealth of Virginia Va. Code § 63.2-1937 CASE NO. .............................................................................................. 1 [ ] Circuit Court ....................................................................................................................................... [ ] Juvenile and Domestic Relations District Court 2 3 ..................................................................................................................... v. ...................................................................................................................... PETITIONER RESPONDENT/OBLIGOR

4 5 ..................................................................................................................... ...................................................................................................................... ADDRESS/LOCATION ADDRESS/LOCATION

6 7 ..................................................................................................................... ...................................................................................................................... Social Security No. ............................................................................ Social Security No. .............................................................................

DECEMBER 2007

Telephone No. (H) ................................. (W) ................................. Telephone No. (H) ................................ (W) ..................................

8 10 11

9 12 13

Date of Birth ......................................................................................... Date of Birth ..........................................................................................

14

15 ..............................................................................................................................................................................................................................................................

16LICENSING AGENCY

..............................................................................................................................................................................................................................................................

ADDRESS OF LICENSING AGENCY

16 ........................................................................................................................................................................................................ ......... ........................................ I, the undersigned petitioner, state under oath to the best of my knowledge that the above named obligor is [ ] delinquent in the payment of child support by a period of ninety days or more or for $5,000 or more, or [ ] has failed to comply with a subpoena, summons or warrant relating to paternity or child support proceedings.

17

Delinquency: ..................................................... days. Alleged amount of delinquency: $ ............................................................

18

19 I have forwarded the notice required in Va. Code § 63.2-1937. A copy of the certified mail certificate with proof of actual receipt is attached. A copy of the notice is also attached. I request that the court suspend the obligor’s license, certificate, registration or other authorization to engage in a business, trade, profession or occupation or recreational activity issued by the Commonwealth. ..............................................................................................................................................................................................................................................................

TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR OTHER AUTHORIZATION

20 ....................... .. ...................................................................................................................................................................... . .................................................... NAME OF LICENSE HOLDER AS IT APPEARS ON THE LICENSE LICENSE NUMBER

21

22 .......................................................................................... _____________________________________________________________ DATE PETITIONER’S SIGNATURE

23 24 Sworn before me this day on .......................................................... DATE

25 ..................................................................................................................... My commission expires on .............................................................. SIGNATURE OF [ ] NOTARY PUBLIC [ ] INTAKE OFFICER NOTARY FORM DC-670 MASTER 10/02



Data Elements

1. Court case number. (Completed by clerk.) 2. City or county where court is located. 3. Check the box of the appropriate court

where petition was filed. 4. Name of petitioner. 5. Name of the respondent/obligor. 6. Petitioner’s address. 7. Respondent’s address. 8. Petitioner’s social security number. 9. Respondent’s social security number. 10. Petitioner’s home phone number. 11. Petitioner’s work phone number. 12. Respondent’s home phone number. 13. Respondent’s work phone number. 14. Petitioner’s date of birth. 15. Respondent’s date of birth. 16. Name and address of licensing agency. 17. Alleged nature of delinquency or failure to

comply. 18. Alleged duration of delinquency. 19. Alleged amount of delinquency. 20. Type of license of which the petitioner seeks

revocation. 21. Obligor’s name as it appears on the license. 22. License number.

23. Date signed. (Complete before Intake Officer or Notary).

24. Signature of the petitioner. (Do not

complete on-line.) 25. This must be signed before a notary or

intake officer who will fill out this portion of the form appropriately. (Do not complete on-line.)

Form DC-671 ORDER FOR SUSPENSION OF PROFESSIONAL Page: 1 OR OTHER LICENSE


Using This Form

1. Copies –

a. Original – court b. Copy – Respondent

c. Copy – Petitioner

2. Prepared by clerk, signed by judge. 3. Attachments – none. 4. Preparation details –

a. This order is used by the court to suspend the professional or recreational license of an obligor who is found to be delinquent in child support payments 90 days or more or delinquent in any amount of $5,000 or more.

b. If the court orders the license suspended, the respondent/obligor is ordered to surrender

the professional or other license within 90 days to the agency responsible for issuing the license. The license is not surrendered to the clerk.



ORDER FOR SUSPENSION OF PROFESSIONAL OR OTHER LICENSE Commonwealth of Virginia Va. Code § 63.2-1937 CASE NO. .............................................................................................. 1

[ ] Circuit Court ....................................................... ............................................................................. [ ] Juvenile and Domestic Relations District Court 2 ..................................................... .............................................................. v. ........................................................... ......................................................... 3 3 PETITIONER/OBLIGEE RESPONDENT/OBLIGOR ..................................................................................................................... ...................................................................................................................... ADDRESS/LOCATION ADDRESS/LOCATION ..................................................................................................................... ...................................................................................................................... Social Security No. ............................................................................ Social Security No. ............................................................................. 3 3 Telephone No. (H) ................................. (W) ................................. Telephone No. (H) ................................ (W) ..................................

Date of Birth ......................................................................................... Date of Birth .......................................................................................... 3 3

DECEMBER 2007

..................................................................................................................... ...................................................................................................................... 4

LICENSE NUMBER AMOUNT OF DELINQUENT CHILD SUPPORT PAYMENT .............................................................................................................................................................................................................................................................. 5

NAME OF LICENSING AGENCY ..............................................................................................................................................................................................................................................................

ADDRESS

.............................................................................................................................................................................................................................................................. CITY/STATE/ZIP

[ ] Upon review of the facts, I find that the respondent (i) [ ] is delinquent in the payment of child support by ninety days or more in an amount of $5,000 or more or [ ] has failed to comply with a subpoena, summons or warrant relating to paternity or child support proceedings and (ii) holds a license, certificate, registration or other authority to engage in a business, trade, profession or occupation or recreational activity issued by the Commonwealth, and I order suspension of that license. The respondent is required to surrender any license, certificate, registration or other such authorization to the issuing entity within ninety days of the date on which this order is entered. The respondent may be jailed or fined for contempt of court if the respondent fails to comply with the terms of this order. If, at any time after entry of the order, the respondent (i) pays the delinquency; (ii) reaches an agreement with the obligee or the Department of Social Services and makes at least one payment pursuant to the agreement, and presents proof of payment, or (iii) complies with the subpoena, summons or warrant or reaches an agreement with the Department with respect to the subpoena or summons and provides certification of the compliance or agreement upon motion, the court shall order reinstatement. Payment shall be proved by certified copy of the payment record issued by the Department or notarized statement of payment signed by the obligee. No fee shall be charged to a person who obtains reinstatement of a license, certificate, registration or authorization pursuant to this section.

[ ] The respondent is ordered to notify the petitioning party that the license has been surrendered. [ ]

............................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................

[ ] I do not order suspension of this license because: [ ] Upon review of the facts, I find that an alternate remedy is available and the license is not suspended.

[ ] I find that irreparable harm to the respondent or employees of the respondent would result from a suspension. [ ] I find that a suspension would not result in collection of the delinquency. [ ] I find that the respondent has made a demonstrated, good faith effort to reach an agreement with the obligee or the Department.

6

7

8

9

.......................................................................................... _____________________________________________________________ 10 11

DATE JUDGE FORM DC-671 MASTER 10/02



Data Elements

1. Court case number. 2. Jurisdiction. Check appropriate court where petition was filed. 3. Information on the petitioner and respondent as requested. 4. Dollar amount of child support delinquency. 5. Name and address of agency holding the license in question, and number of license. 6. Check if judge finds license should be suspended, and applicable box indicating basis of

suspension. 7. Check if applicable. Insert any further order of the court. 8. Check if license shall not be suspended. 9. Check appropriate box if Data Element No. 8 is check explaining decision not to suspend. 10. Date order is signed. 11. Signature of judge entering the order.

Form DC-672 Form DC-672CERTIFICATE OF COMPLIANCE FOR

REINSTATEMENT OF PROFESSIONAL OR OTHER LICENSE


This form was developed to complete procedure for the suspension of a professional or otherlicense under Virginia Code § 63.1-263.1 for failure to pay child support. It is used whenrespondent whose professional or other license has had been suspended has either paid in full thesupport arrearage or else has entered into a payment agreement and has made at least onepayment in support of that agreement, or has complied with process or an order of DCSE.


CERTIFICATE OF COMPLIANCE FOR REINSTATEMENT OF PROFESSIONAL OR OTHER LICENSECommonwealth of Virginia Va. Code § 63-2.1937 CASE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DCSE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COURT

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In re/v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PETITIONER RESPONDENT

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS/LOCATION ADDRESS/LOCATION

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The undersigned respectfully represents to the Court that an order dated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . was entered by thisDATE

Court requiring the respondent to surrender his or her license, certificate, registration, or other authority to engage in a business, trade,profession, or occupation or professional or recreational activity to the licensing agency.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NAME OF LICENSING AGENCY LICENSE NUMBER

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ADDRESS OF AGENCY

Pursuant to the Code of Virginia § 63.2-1937, the undersigned requests that the court order the reinstatement of the respondent’slicense, certificate, registration or other authority to engage in a business, trade, profession or occupation or recreational activity to thelicensing agency. In support thereof, the undersigned certifies that the respondent has

[ ] paid the arrears in full.

[ ] signed a payment agreement and made at least one payment according to the agreement.

[ ] complied with the subpoena, summons or warrant or reached an agreement with the Department concerning compliance.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________ DATE PETITIONER

Attachments:

[ ] Case Account Statement [ ] Certification of compliance or agreement

[ ] Payment Agreement [ ] other

ORDER

Upon consideration of certification of payment or compliance as set forth above, respondent’s license, certificate, registration, or otherauthority to engage in a business, trade, profession or occupation or recreational activity is hereby ordered reinstated. Pursuant toVirginia Code § 63.2-1937, no fee shall be charged for reinstatement.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________ DATE JUDGE

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Form DC-672 Form DC-672CERTIFICATE OF COMPLIANCE FOR

REINSTATEMENT OF PROFESSIONAL OR OTHER LICENSE

Data Elements


2. DCSE number (if applicable).

3. Name of court.

4. Name and address of petitioner and respondent.

5. Date of order of suspension of professional license.

6. Name and address of licensing agency and number of license.

7. Basis for seeking reinstatement of license.

8. Date of petition.


10. Attachments.

To be completed by the judge:11. Date of order.


Form DC-680 CONSENT FOR ADOPTION Form DC-680

Using This Form

1. Copies

a. Original – to court. b. First copy – certified, to adoptive parents or to their counsel.

2. Prepared by birth parent and intake officer, signed by birth parent and the judge in court. 3. Attachments – order transferring custody to prospective adoptive parents if consent

accepted.


a. This form is for use when the birth parent has placed the child directly with the adoptive parents.

b. The form must be executed in court in the presence of the adoptive parents unless

the adoptive parents are the child’s grandparents, adult brother or sister, adult uncle or aunt or adult great uncle or great aunt.

c. The child must be at least 10 days old at the time the consent is executed.

d. Revocation of consent must be made within 7 days of the execution of the

consent, and filed in the clerk’s office during the business day of the court.


CONSENT FOR ADOPTION Case No. ................................................................................................. 1

Commonwealth of Virginia VA. CODE §§ 63.2-1232, 63.2-1233, 63.2-1234

............................................................................................................................................................................... Juvenile and Domestic Relations District Court 2

In re: .................................................................................................................................................................................................................................................................. 3

I, having been sworn, state under oath as follows: 1. I, .............................................................................................................. , am the birth [ ] mother [ ] father of the child named above: 4

...................................................................................................................................................................................................................................................................... 5

ADDRESS 2. I am aware of alternatives to adoption, adoption procedures, and opportunities for placement with other adoptive families, and my

consent is informed and uncoerced; 3. I have exchanged identifying information with the adoptive parents including but not limited to full names, addresses, physical,

mental, social and psychological information and any other information necessary to promote the welfare of the child; 4. I have disclosed to the court any financial agreement or exchange of property between me and the adoptive parents and any fees

charged or paid for services related to the placement or adoption of the child; I understand that no binding contract regarding placement or adoption of the child exists;

5. I have been informed of my opportunity to be represented by legal counsel;

[ ] a. My counsel is: ..................................................................................................................................................................................................................... NAME .................................................................................................................................................................................................................................................... ADDRESS TELEPHONE NUMBER [ ] b. I have declined to be represented by counsel.

6. I am aware that if I knowingly and intentionally provide false information in writing and under oath which is material to an adoptive placement I shall be guilty of a Class 6 felony under Virginia Code § 63.2-1217; and

7. By signing this consent to adoption, I acknowledge that I do so in the belief that such action will promote the best interest of such

child. My consent and signature here are given freely, knowingly, voluntarily, with full knowledge of its meaning and effect, and without any threats, promises, force, improper influence or any other kind of coercion.

I understand that I may revoke this consent, in writing, for any reason, for up to 7 days from the date of my signing this consent. My revocation must be filed with the clerk of the court in which this consent is executed. I understand that my revocation must be filed within 7 days of the signing of this consent and that, if the revocation period expires on a Saturday, Sunday, legal holiday or any day on which the clerk’s office is closed as authorized by statute, the revocation period shall be extended to the next day that is not a Saturday, Sunday, legal holiday or other day on which the clerk’s office is closed, as authorized by statute. I further understand that, upon the filing of a valid revocation, the court shall determine custody of my child as between the birth parents. I further understand that I may waive my right to a 7-day period in which to revoke this consent. Given under my hand this date:

....................................................................... _______________________________________________________________________ 7 8

DATE [ ] BIRTH MOTHER [ ] BIRTH FATHER

Sworn to and subscribed to before me in open court, and in the presence of the adoptive parents, this date: ....................................................................... _______________________________________________________________________ 9 10

DATE JUDGE


Form DC-680 CONSENT FOR ADOPTION Form DC-680


Data Elements

1. Court case number. 2. Court name.

3. Name of child to be adopted.

4. Name of birth parent executing the form; check appropriate box.

5. Address of birth parent executing the form.

6. Check appropriate box. Insert name, address and telephone number of the attorney

representing this birth parent, if applicable.

7. Date form signed by birth parent.

8. Signature of birth parent.

9. Date form signed by the judge.

10. Judge’s signature.

Form DC-684 FILING OF FOREIGN PROTECTIVE ORDER Form DC-684

Using This Form

1. Prepared and signed by individual requesting filing; signed and/or acknowledged by clerk.

2. Attachments – certified copy of an order of protection from another state of the United

States or from a tribal court.


a. This form allows an individual to file the order of an out-of-state court with a Virginia court for potential enforcement under Virginia Code § 16.1-279.1(E). After filing, the foreign order is enforceable by a juvenile and domestic relations district court as if it were an order of a Virginia court.

b. The clerk, in case of future action toward enforcement, should assign a case

number (Data Element No. 1), and the defendant/respondent’s descriptive information (Data Element No. 15) should be entered in the Virginia Criminal Information Network (VCIN).


FILING OF FOREIGN PROTECTIVE ORDER Case No. ........................................................................................

1 Commonwealth of Virginia VA. CODE § 16.1-279.1

COMPLETE DATA BELOW IF KNOWN BORN HT. RACE SEX

MO. DAY YR. FT. IN.

WGT. EYES HAIR

SSN

................................................................................................................................................................................................................................................................. Court

2 Name of Party Filing Foreign Protective Order: .................................................................................................................................................................... Virginia Address of Party Filing Order: ......................................................................................................................................................................................

3

4 Name of Person(s) Protected by the Order: ............................................................................................................................................................................... Name of Defendant/Respondent: ..................................................................................................................................................................................................... Issuing Jurisdiction: ................................................................................................................................................................................................................................. STATE COUNTY OR CITY

5

6

7 Name of Court which issued Order: .......................................................................................... Case No. ..........................................................................

8 Date of Entry: ...................................................................................................... Expiration Date (if any): ......................................................................

9

10

10 ______________________________________________________________ SIGNATURE OF PARTY FILING ORDER

11

Defendant/Respondent’s Description (for VCIN entry): Full Name: ................................................................................................................................................................................................................................................................................

12 Address: ..................................................................................................................................................................................................................................................................................... Telephone No. .............................................................................................

13

14

15

CLERK’S CERTIFICATION An attested or exemplified copy of the above-identified foreign protective order has been filed with this Court. ....................................................................... ______________________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK

16

17


Form DC-684 FILING OF FOREIGN PROTECTIVE ORDER Form DC-684


Data Elements

1. Court case number (completed by the clerk of court).

2. Court jurisdiction or court name.

3. Name of individual requesting filing of out-of-state protective order.

4. Address in Virginia of individual requesting filing.

5. Names of persons protected by the order.

6. Name of defendant/respondent against whom order entered.

7. Jurisdiction of court issuing order, for example, “Kansas. . . . Wichita”.

8. Type of court (or name of court) that issued order.

9. Case number of out-of-state case.

10. Date order entered and expiration date, if applicable.

11. Signature of individual requesting filing. (Please leave blank and print the form before signing if completing the Internet form.)

12. Full name of defendant/respondent.

13. Address of defendant/respondent.

14. Telephone number for defendant/respondent.

15. Identifying information for respondent, if known.

16. Date out-of-state order filed in Virginia court.

17. Signature of clerk/deputy clerk.

Form DC-686 NOTICE OF REGISTRATION OF SUPPORT ORDER Page: 1

Using This Form

1. Copies


b. First copy – to non-registering party.

c. Second copy – to registering party. 2. Prepared by clerk. 3. Attachments

a. Form DC-685, REQUEST FOR VIRGINIA REGISTRATION OF FOREIGN SUPPORT ORDER

b. Foreign support order(s) pertaining to the request

c. Any other documents and relevant information accompanying the order 4. Preparation details

a. This form is intended for use with the form DC-685, REQUEST FOR VIRGINIA REGISTRATION OF FOREIGN SUPPORT ORDER, to implement the registration provisions of the Uniform Interstate Family Support Act (UIFSA), Virginia Code ∋∋ 20-88.32 through 20 -88.82.

b. Upon the receipt of a completed form DC-685, REQUEST FOR VIRGINIA REGISTRATION OF

FOREIGN SUPPORT ORDER, the clerk should prepare form DC-686. Copies of the completed forms DC-685, DC-686, the foreign support order(s)pertaining to the request and any other documents and relevant information accompanying the order may be mailed to the non-registering party by first class, certified or registered mail or served on the non-registering party by personal service or given by other means. Virginia Code §20-88.70(A).

c. The non-registering party must request a hearing within 20 days of the date of notice if he

or she desires to contest the registration. Virginia Code §20-88.71(A).

d. If the order sought to be enforced is an income-withholding order, the clerk shall notify the obligor's employer in the same manner as for entry of the form DC-645, INCOME DEDUCTION ORDER OF SUPPORT, upon the receipt of DC-685 requesting such registration/enforcement (Data Element Nos. 10-13).



NOTICE OF REGISTRATION OF SUPPORT ORDER Case No. ........................................................................................

1 Commonwealth of Virginia Va. Code §§ 20-88.67, 20-88.70 DCSE ID No. .............................................................................. 2


............................................................................................................................................................................... Juvenile and Domestic Relations District Court CITY/COUNTY

3 ...............................................................................................................................................................................................................................................................................

COURT ADDRESS

4

NOTICE TO NON-REGISTERING PARY [ ] OBLIGEE [ ] OBLIGOR 5 A request for Virginia Registration of Foreign Support Order has been filed pursuant to Va. Code § 20-88.67 for [ ] enforcement and/or [ ] modification. The registered order(s) is/are enforceable in this court as of the date of registration. If you wish to contest the validity or enforcement of the registered order(s) you must file a written request for a hearing in the clerk’s office within twenty days of the date of mailing or the personal service of this notice.

6

FAILURE TO CONTEST THE VALIDITY OR ENFORCEMENT OF THE REGISTERED ORDER(S) IN A TIMELY MANNER WILL RESULT IN CONFIRMATION OF THE ORDER(S), ENFORCEMENT OF THE ORDER(S), AND THE ALLEGED ARREARAGE AND PRECLUDES FURTHER CONTEST OF THAT ORDER(S) WITH RESPECT TO ANY MATTER THAT COULD HAVE BEEN ASSERTED AND OF THE AMOUNT OF THE ALLEGED ARREARAGE.

7 [ ] I certify that a copy of this Notice, a copy of the Request for Virginia Registration of Foreign Support Order and a copy of the order(s) to be registered along with all documents or relevant information accompanying the order(s) was given on

................................................................................. by [ ] first class mail [ ] certified mail [ ] registered mail DATE

[ ] other .................................................................................................................................................................................................................................................. to [ ] obligee (Name/Address) .............................................................................................................................................................................................. .............................................................................................................................................................................................................................................................

8 to [ ] obligor (Name/Address) .............................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. named on the attached Request for Virginia Registration of Foreign Support Order.

9 [ ] FOR ENFORCEMENT REGISTRATION OF INCOME-WITHHOLDING ORDERS I further certify that a copy of the REQUEST FOR VIRGINIA REGISTRATION OF FOREIGN SUPPORT ORDER, Form DC-685, requesting

the registration of the Income Withholding order for enforcement and the Certification of Arrearage and a copy of the order(s) to be registered along with all documents or relevant information accompanying the order(s) was given by

[ ] personal delivery [ ] other ..........................................................................................................................................................................................

[ ] first class mail [ ] certified mail [ ] registered mail to the obligor’s employer as follows: (Name/Address)

10 ......................................................................................................................................................................................................................................................................

......................................................................................................................................................................................................................................................................

11......................................................................................................................................................... on .................................................................................................... DATE

12

.......................................................................................... _______________________________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK

13

14

RETURN

NAME:

ADDRESS:

[ ] PERSONAL SERVICE TELEPHONE NUMBER:

[ ] NOT FOUND

_________________________________________________________________ SERVING OFFICER

DATE AND TIME:

15

16

17

18

19

FORM DC-686 (MASTER 10/07


Data Elements

1. Court case number. 2. Division of Child Support Enforcement case number. 3. Court name. 4. Court street address. 5. Check appropriate box. 6. Check appropriate box(es). 7. Check box and insert date and method of sending/giving notice. 8. Check appropriate box and insert name and address of appropriate party. 9. Check box if applicable. 10. Check box showing method of sending or giving notice. 11. Insert name of obligor’s employer if applicable. 12. Date on which notice mailed to obligor’s employer. 13. Date signed by clerk or deputy clerk. 14. Clerk or deputy clerk’s signature. 15. Name and address of party on whom the notice was personally served, if applicable. 16. Telephone number of party served. 17. Check appropriate box. 18. Signature of serving officer. 19. Date and time of service.


Documents

DC-600S DOMESTIC RELATIONS